St Peters Rehab And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to respond to call lights in a timely manner for three residents (Resident #12, #3 and #8), in a review of 18 sampled residents. The facility census was 87. Review of the facility's policy, Communication - Call System, revised 10/24/22, showed the following: -The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities; -Nursing staff will answer call lights promptly; -Call lights located within resident bathrooms are considered emergency calls due to the potential for falls and injury and must be answered promptly. 1. Review of Resident #12's admission record showed the resident's diagnoses included dementia, arthritis, muscle weakness, cognitive communication deficit, and other abnormalities of gait and mobility. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/02/24, 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 interview and record review, the facility failed to clarify and obtain physician orders for two residents (Resident #1 and #2), in a review of 18 sampled residents, who sustained fractures and had surgery to repair, for assessment and treatment of each residents' surgical incisions when they admitted to the facility from the hospital. The facility failed to complete neurological checks per facility policy following a fall for one resident (Residents #2), in a review of 18 sampled residents. The facility census was 87. Review of the facility's policy, Physician Orders, revised October 24, 2022, showed the following: -Purpose: This will ensure that all physician orders are complete and accurate; -Treatment orders will include a description of the treatment, including the treatment site, if applicable, the frequency of treatment and duration of order (when appropriate) and the condition/diagnosis for which the treatment is ordered. Review of the facility policy, Response to Falls, revised October 24, 2022,…

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.

See event ID 6GI312 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 4/12/24. Based on observation, interview, and record review, the facility failed to provide adequate staffing and oversight to ensure residents that required staff assistance were showered, clean, hair maintained, shaving completed, nails trimmed and call lights answered for eight residents, in a review of 25 sampled residents. The facility failed to ensure sufficient staff to provide regular baths or showers and meet hygiene needs for two residents (Resident #32 and Resident #310) and did not respond to resident call lights in a timely manner for eight residents (Resident #304, #2, #310, #306, #4, #20, #307 and #313) , resulting in the resident's toileting needs not being met and episodes of incontinence or resident's being left soiled for extended times. The facility also failed to provide adequate staff to ensure the facility was clean and free of odors. The facility census was 81.

See event ID 6GI312 Based on observation, record review, and interview, the facility failed to provide a safe, clean and comfortable environment by failing to ensure resident rooms and living spaces were clean and in good repair. The facility census was 81.

See event ID 6GI312 Based on observation, interview, and record review, the facility failed to follow physician orders for three residents (Resident #305, #20 and #224) in a review of three sampled resident reviewed. Resident #305 did not receive his/her insulin (injection of hormone that regulates blood sugar) which resulted in the resident's blood sugar exceeding the parameters set by the physician as acceptable. The facility staff failed to identify the missed dose of insulin or document proper notification of the physician, or continued assessment of the resident with a blood sugar of 499. The facility also failed to provide medications as ordered by the physician and did not contact the physician for further direction when orders could not be followed. The facility census was 81.

See event ID 6GI312 This deficiency is uncorrected. For previous examples, see the Statement of Deficiency dated 4/12/24. Based on observation, interview and record review, the facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 81.

See event ID 6GI312 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 4/12/24. Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #32 and Resident #310), of 25 sampled residents, who required assistance with activities of daily living (ADL) received the necessary care and services to maintain good grooming and personal hygiene. The facility census was 81.

See event ID 6GI312 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 4/12/24. Based on observation, interview, and record review, the facility failed to ensure interventions to address weight loss, including physician ordered supplements were provided and registered dietician (RD) recommendations followed to prevent further weight loss for two residents (Resident #30 and #32), in a review of 25 sampled residents. The facility failed to ensure the residents received the necessary services and assistance to maintain their nutritional status and to prevent weight loss. The facility census was 81.

Based on interview, policy review, and job description review, the facility failed to ensure there was a qualified Activity Director (AD) to oversee the activity program. This created the potential for the activity program to not be administered effectively and to not meet the needs, interests, and preferences of all 82 residents who resided in the facility. The facility census was 82. Findings include: Review of the facility's policy titled, Activities Program dated 10/24/22 revealed, The Facility provides an Activity Program designed to meet the needs, interests, and preferences of residents .an individualized Care Plan will be developed and implemented for each resident .The resident's activity plan will be reviewed and updated at least quarterly . No less than quarterly, the Director of Activities or his or her designee will make a progress note .The Activity Department will maintain accurate records of each resident's participation in group, independent and room visit involvement. Participation will be documented daily . Review of facility's Activity Director (AD) job…

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, facility policy review, and staffing schedule review, the facility failed to ensure there was adequate competent nursing department staffing, in adequate numbers to meet the needs of five of 28 sampled residents (Resident (R) 20, R13, R14, R4, and R16) and six supplemental residents (R5, R70, R6, R118, R224, and R41). Residents did not receive medications; did not have their call lights answered timely and/or they had unmet needs; activities of daily living (ADLs) were not provided for residents requiring assistance; and residents were not provided ice water in their rooms or sufficient beverages. Weekend staffing and agency staff were common problems expressed by the residents. The facility census was 82. Findings include: Review of the facility's policy titled, Nursing Department - Staffing, Scheduling & Postings dated 10/24/22 revealed, Purpose: To ensure an adequate number of nursing personnel are available to meet resident needs. The Facility will employ…

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 nourishment refrigerators free from grime and food residue on the inside and that temperatures were checked. These failures had the potential to affect all 82 residents. Findings include: Review of the facility's policy titled, Cleaning Scheduled, stated, The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager. The Dietary Manager will develop a cleaning schedule that includes the frequency of which equipment, and areas are to be cleaned. The cleaning schedule is posted weekly. The cleaning schedule includes tasks assigned to specific positions within the dietary department. Dietary staff will initial next to the assigned task once it is completed. The Dietary Manager monitors the cleaning schedule to ensure compliance. Observation on 04/10/24 at 1:30 PM revealed the nourishment refrigerator in the front dining hall had spilled juice at the bottom and contained 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.

Based on interview, record review, and facility policy review, the facility failed to ensure the Infection Prevention and Control Program (IPCP) was overseen by an Infection Preventionist (IP) who had completed specialized training in infection prevention and control (IPC). This had the potential to affect 82 of 82 residents who resided at the facility. The facility census was 82. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website at https://www.train.org/cdctrain/training_plan/3814 revealed, . This course will provide infection prevention and control (IPC) training for individuals responsible for IPC programs in nursing homes so they can effectively implement their programs and ensure adherence to recommended practices by front-line staff. The course will include information about the core activities of an effective IPC program, with a detailed explanation of recommended IPC practices to prevent pathogen transmission and reduce healthcare-associated infections and antibiotic resistance in nursing homes. Additionally, this course will provide…

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 the wireless call light system to ensure staff carried pagers to alert them to residents' calls for staff assistance as required by the exception granted to the facility for seven residents (Resident #301, #306, #4, #20, #307, #14 and #300) of 25 sampled residents. Review of the call light response time log, showed staff did not respond to call lights timely, with residents experiencing extensive wait times of over an hour on each resident hall. This had the potential to affect all residents. The facility census was 81. Review of a letter from the Department of Health and Senior Services to the facility, granting the exception for the use of a wireless nurse call system, dated 9/20/22, showed the following: -The facility will ensure the wireless nurse call system is fully operational twenty-four hours per day, seven days a week; -The facility will ensure that all direct care staff carry and utilize the wireless nurse call pagers…

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 bariatric incontinent briefs in ample supply to meet residents' needs for three of three sampled residents (Resident (R) 4, R14, and R20) reviewed for accommodation of needs. The facility census was 82. Findings include: 1. Review of R4's admission Record, provided by the facility, revealed R4 was admitted to the facility on [DATE] with diagnoses that included severe obesity. Review of R4's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/28/23 and located under the MDS tab of the electronic medical record (EMR), revealed R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 04/08/24 at 4:00 PM, R4 stated the facility did not have the size incontinent brief that she required, and the facility always ran out of bariatric briefs. During an observation and interview on 04/10/24 at 12:25 PM, R4 reported 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, record review, and facility policy review, the facility failed to ensure grievances raised by the resident council were addressed and attempts were made to resolve the grievances for six of six residents who attended the resident council group interview (Resident (R) 5, R70, R18, R224, R41, and R20). Ongoing concerns included: call lights, staff not introducing themselves, staff not responding to residents' needs, staff talking on their phones, and food palatability issues. The facility census was 82. Findings include: Review of the facility's policy titled, Grievances and Complaints dated 10/24/22 revealed, The facility . ensures that there is a prompt review, investigation and response to and resolution of grievances and complaints . The policy did not include specific information related to grievances expressed during the resident council meeting. A resident council group interview was held on 04/10/24 at 2:30 PM with R70, R5, R18, R224, R41, and R20 in attendance. Their comments included: -All six residents stated the issues raised 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure residents and/or their representative received written information about and assistance with formulating advance directives for three of three residents reviewed for advance directives (Resident (R) 4, R16, and R14) out of 28 sampled residents. The facility census was 82. Findings include: 1. Review of R4's admission Record, provided by the facility, revealed R4 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis, type 2 diabetes mellitus, and severe obesity. Review of R4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/23 and located in the electronic medical record (EMR) under the MDS tab, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R4 was cognitively intact. Review of R4's Social Services Quarterly Note, dated 03/12/24 and provided by the Administrator, recorded, . Advanced Directives 1. Has 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, record review, and interview, the facility failed to provide a safe, clean and comfortable environment by failing to ensure resident rooms and living spaces were clean and in good repair. The facility census was 81. Review of the facility policy, Resident Rooms and Environment, dated 10/24/22, showed the following: -The facility provides residents with a safe, clean, comfortable and homelike environment. Facility staff will provide residents with a pleasant environment; -Facility staff aim to create a personalized, homelike atmosphere, paying close attention to cleanliness, odor and pleasant, neutral scents. 1. Observation on 6/17/24 at 10:30 A.M., upon entrance to the facility, showed a strong urine odor in the main dining room where several residents sat at tables, visiting and watching television. 2. Observation on 6/17/24 at 11:00 A.M., during a tour of the building, showed the following: -Strong urine odors on each hallway; -Strong urine and feces odors on the 500 hall; -Multiple…

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 physician orders for three residents (Resident #305, #20 and #224) in a review of three sampled resident reviewed. Resident #305 did not receive his/her insulin (injection of hormone that regulates blood sugar) which resulted in the resident's blood sugar exceeding the parameters set by the physician as acceptable. The facility staff failed to identify the missed dose of insulin or document proper notification of the physician, or continued assessment of the resident with a blood sugar of 499. The facility also failed to provide medications as ordered by the physician and did not contact the physician for further direction when orders could not be followed. The facility census was 81. Review of the facility policy, Physician Orders, dated 10/24/22, showed the following: -The purpose is to ensure that all physician orders are complete and accurate; -The medical records department will verify that physician orders are complete,…

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 sufficient activities were provided to one of 28 sample residents (Resident (R) 20) and all five of five supplemental residents (R70, R5, R18, R51, R224, and R41). Failures included not offering activities on the weekends or offering outings. Activity participation was not documented; quarterly activity progress was not completed; and a care plan was not developed for R51 as directed by the facility's policy. The facility census was 82. Findings include: Review of the facility's policy titled, Activities Program dated 10/24/22 revealed, The Facility provides an Activity Program designed to meet the needs, interests, and preferences of residents . A variety of activities should be offered on a daily basis, which includes weekends and evenings . After completion of the initial Activity Assessment and the MDS, an individualized Care Plan will be developed and implemented for each resident .The resident'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 observation, interview, record review, and facility policy review, the facility failed to offer/provide adequate fluids such as ice water and other beverages to two of 28 sampled residents (Resident (R)13 and R20) and to four of five supplemental residents ( R70, R18, R41, R224) attending the resident council group interview. An initial nutritional assessment was not completed by the Registered Dietitian for R13; R13 was not offered and was not documented as consuming adequate fluids. The facility census was 82. Findings include: Review of the facility's policy titled, Nutrition/Hydration Management dated 10/24/22 revealed, The concept of nutrition management is an interdisciplinary process. The key components of this system are: Maintaining nutritional status as indicated by clinical measures such as body weight, biochemical measure, and hydration .Within seven (7) days of admission, a registered dietitian completes a thorough nutritional assessment providing a more detailed profile of the resident'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 observation, interview, record review, and review of the facility's policy, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for Resident (R) 14 were made out of 25 opportunities. The medication error rate was 8 percent. The facility census was 82. Findings include: Review of the facility's policy titled, ''Medication Administration'' revised 10/24/22 read in part, Medications will be administered by a licensed nurse per the order of an attending physician or licensed practitioner or as consistent with the state law . When preparing medications. The nurse will do a three-part check. Compare the licensed practitioner prescription with the medication administration record (MAR). Compare the licensed practitioner's order with the pharmacy label on the medication package. Compare the pharmacy label and the MAR. Any discrepancy identified during the first, second and third check must be resolved prior to the administration of 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, interview, record review, and facility policy review, the facility failed to ensure condiments were offered and served with food for three of 28 sampled residents (Resident (R) 174, R13, and R41). The facility census was 82. Findings Include: Review of the facility's policy titled, Dietary Department- General revised 10/24/22, revealed The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. The primary objectives of the dietary department include Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and accommodates resident allergies, intolerances, and preferences. 1. During the initial tour on 04/08/24 at 10:45 AM, an interview was conducted with R174. The resident stated she was admitted to the facility a few days ago. R174 stated no condiments were served with the meals. Observation on 04/10/24 at 9:15 AM R174 was served a breakfast tray 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 Based on observation, interview, record review, and policy review, the facility failed to ensure three of 28 sampled residents (Resident (R) 30, R28, and R63) received services in a manner that promoted their dignity and enhanced their quality of life. R30 was observed as unshaven with long stubble facial hair and wearing clothing covered with food spills, residue, and crumbs. R28 and R63 required assistance with eating and facility staff were observed standing over them while assisting them. The facility census was 82. Findings include: Review of the Privacy and Dignity policy, dated 10/24/22 revealed, The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality . Staff assists residents in maintaining self-esteem and self-worth. Residents are groomed as they wish to be groomed. Residents are dressed appropriate to the time of day and season as well as individual preferences . The facility respects 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 interview, record review, and policy review, the facility failed ensure residents retained their right to exercise their rights for one of 28 sampled residents (Resident (R) 73). The facility did not provide R73 the opportunity to make their own decision regarding whom they wanted to contact and if they wanted to use a cell phone sent to them to communicate. The facility opened the resident's mail containing a cell phone, read a note inside the package intended for the resident, and contacted (Family Member (F) 73. FM 73 told the facility to not give the phone to the resident, even though the resident had not been adjudged incompetent by the court and legally retained his rights as a United States citizen. The facility census was 82. Findings include: Review of the facility's Resident Rights policy dated 05/01/23 revealed, Purpose - To promote and protect the rights of all residents at the facility .All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Facility . Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to invite two of 28 sampled residents (Resident (R) 11 and R4) to participate in their care plan meetings. Both residents had been assessed as cognitively intact and expressed they would like to attend their own care plan meetings. The facility census was 82. Findings include: Review of the facility's policy titled, Care Planning dated 10/24/22 revealed, The Comprehensive Care Plan must be prepared by the IDT [interdisciplinary team]. The IDT team includes the following individuals . The resident and/or his/her family or legal representative; i. If the resident and his/her resident representative participation is determined not practicable for the development of the resident's care plan, an explanation should be included in the resident's medical record . The Facility will invite the resident, if capable, and their family to care planning meetings and use its best efforts to schedule care planning meetings at times convenient 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, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 43) reviewed for room change out of a total sample of 28 residents were provided with written notice of room change, including the reason for the change, prior to the facility-initiated room change occurring. The facility census was 82. Findings include: Review of the facility's policy titled, Room or Roommate Change, dated 10/24/22 revealed, Purpose - To ensure that a resident is able to exercise their right to change rooms or roommates .Prior to changing a room or roommate assignment, the resident, the resident's representative (if available), the resident new roommate, and the resident current roommate will be given timely advance notice of such change. A. When the resident is being moved at the request of the Facility, the notice of a change in room assignment will be in writing and will include the reason (s) for such change . Social Services Staff will assist 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, record review, and review of the facility's policy, the facility failed to complete an investigation for one of one resident reviewed for grievances (Resident (R) 33) out of 28 sampled residents. The facility failed to inform R33 of the outcome of an investigation into his/her missing brooch. The facility census was 82. Findings include: Review of the facility's policy titled, Grievances and Complaints revised 10/24/22 reads in part .The Facility ensures that there is no retaliation for filing a grievance or complaint and ensures that there is a prompt review, investigation and response to and resolution of grievances and complaints. The disposition of all resident grievances and/or complaints is recorded in the Facility's Resident Grievance/Complaint Log .The facility will inform the resident or his/her representative of the findings of the investigation and any corrective actions recommended in a timely manner . Review of R33's undated admission Record, located in the resident's electronic medical records (EMR) under the Profile tab revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to ensure residents were provided with a bed hold notice within 24 hours of emergent transfer to the hospital for one of three residents (Resident (R) 30) reviewed for hospitalizations out of a total sample of 28. This failure placed R30 and/or his Responsible Party at risk of not knowing to request a bed hold to be able to return to the facility. The facility census was 82. Findings include: Review of the facility's policy titled, Bed Hold, dated 10/24/22 revealed the purpose was, To ensure that the resident and/or their representative is aware of the Facility's bed-hold policy .the Facility advises residents or his/her personal representative in writing that the Facility has a bed hold policy and will hold the resident's bed for the state specified period, if the resident is transferred to a general acute care hospital . Review of the facility's policy titled, Transfer and Discharge, dated 10/24/22 revealed, Before the Facility transfers…

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 activities of daily living (ADL) care for one of seven residents reviewed for ADLs (Resident (R) 176) out of 28 total sampled residents. R176, who was totally dependent on staff for ADLs, and was admitted on [DATE], did not receive a shower until 4/10/24. The facility census was 82. Finding include: Review of the R176's undated admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage III and dementia. Review of R176's five day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/24 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident required substantial to maximum assistance with toileting and personal hygiene (showers and bathing). Review of R176's Care Plan initiated on 03/26/24 and located in the resident'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 observation, interview, record review, and facility policy review, the facility failed to ensure Resident #16 was offered a smoking apron to prevent accidents while smoking, per her care plan. Additionally, the facility failed to care plan what staff should do if the resident refused the smoking apron and failed to ensure all staff were aware of the resident's assessed need for the smoking apron for safety. This affected one of two sampled residents reviewed for smoking out of a sample of 28 residents. The facility census was 82. Findings include: Review of the facility's policy titled, Smoking by Residents, revised 10/24/22, revealed, . Residents who are not able to smoke independently and safely will be accompanied by Facility Staff while smoking . Resident who smoke shall wear a smoking apron if they are found not to be safe (i.e., drop lit cigarettes or do not handle the ashes properly.) . If clothing is found to have cigarette burn holes the smoker must wear an apron to protect themselves from…

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 review of facility's policy, the facility failed to ensure residents' indwelling catheters were properly positioned and secured to promote adequate drainage and prevent reoccurring urinary tract infections for one of two residents (Resident (R) 173) reviewed for catheters out of a total sample of 28 residents. The facility census was 82. Findings include: Review of facility's policy titled Care of Catheters revised 10/24/22 revealed, .Take care to ensure the collection bag does not touch the floor at any time .Collection bags should always be kept below the level of the bladder, including during transport .The catheter and collection tubing should be free of obstruction and kinking. Catheter tubing should be secured to prevent dependent loops .Anchor the catheter with a leg strap to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter . Review of R173's undated admission Record located in the resident'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 observation, interview, record review, and review of facility's policy, the facility failed to maintain oxygen therapy equipment for one of three residents reviewed for oxygen (Resident (R) 46) out of a total sample of 28 residents. R46's oxygen tubing and humidifier bottle were not changed and not dated. Additionally, the oxygen concentrator filter had a heavy accumulation of gray dust debris. The facility census was 82. Findings include: Review of the facility's policy titled, Oxygen Administration revised 10/24/22 read in part .All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled or as indicted by the state regulations . Review of R46's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia. Review of R46's Physicians Orders for the month of April 2024…

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, policy review and job description review, the facility failed to provide medically-related social services to ensure residents maintained their highest practicable wellbeing for three out of 28 sampled residents (R73, R43, and R11). R43 was not provided with a room change notice prior to a room change, had only one set of clothing to wear for a week following the room change. R73 was not given the opportunity to make his own decisions regarding the possession of his phone; the SSD followed the Power of Attorney's wishes without determining what R73 wanted. R11 was not invited to his care plan meeting; the resident's family was invited and the meeting was scheduled around the family's availability. The Social Service Director was the only social services employee and she was routinely assigned to provide direct care service tasks. The facility census was 82. Findings include: Review of the Social Services Director job description revealed, The Social Services…

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 provide medications, as ordered by the physician, to meet the residents' needs for two of five sampled residents (Resident (R) 20 and R4) whose medications were reviewed. The facility census was 82. Findings include: 1. Review of the facility's policy titled, Pain Management, revised 10/24/22, revealed, . Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain . Review of R20's admission Record, provided by the facility, revealed R20 was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis, polyneuropathy, chronic pain, and fibromyalgia. Review of R20's Physician Orders, dated 12/01/22 and located under the Orders tab of the electronic medical record (EMR), revealed R20 was to receive hydrocodone-acetaminophen (Norco, an opioid analgesic) 10/325 milligrams (mg) two tablets by mouth every six…

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 review of the facility's policy, the facility failed to ensure one of five medication carts and one of two treatment carts were locked and secured on two of five resident halls. Additionally, the facility failed to ensure medication refrigerator temperature logs were maintained in one of two medication rooms. The facility census was 82. Finding include: Review of the facility's policy titled, Storage of Medications revised November 2020, read in part The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended .Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled according . 1. Observation on 04/09/24 at 11:56…

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 14 of 23 sampled residents (Resident #5, #6, #7, #8, #9, #11, #13, #14, #15, #16, #18, 19 #20, and #21) when staff failed to administer all medications as ordered and in a timely manner. Facility staff failed to document when a narcotic was administered on the medication administration record (MAR) for one resident (Resident #10) who had a G-tube (a tube inserted through the belly that brings nutrients directly to the stomach), and failed to routinely document narcotic administration, assess and document the pain level for an as needed (PRN) narcotic for one resident (Resident #12) after facility staff signed out narcotics on the individual narcotic record. The facility failed to ensure power cords were available and accessible for staff to charge laptops and access physician orders so medications could be administered in a timely manner and failed to ensure new staff members were aware of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Document under event id WVYK12 Based on observation, interview, and record review, the facility failed to ensure resident and staff testing for COVID-19 (coronavirus disease, caused by the SARS-CoV-2 virus) was completed according to facility policy for COVID-19 during an outbreak. The facility failed to ensure staff changed gloves and washed hands as indicated during the provision of care for three residents (Residents #2, #9 and #13) in a review of 16 sampled residents. The facility failed to ensure use of proper personal protective equipment (PPE) when staff entered COVID-19 positive rooms and failed to discard of trash from isolation rooms appropriately. The facility census was 86. 1. Review of the facility policy, Coronavirus Disease (COVID-19) - Testing Residents, dated May 2023, showed the following: -Residents are tested for the SARS-CoV-2 virus to detect the presence of current infections and to help prevent the transmission of COVID-19 in the facility; -Asymptomatic residents with close contact 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 Document under event id WVYK12 Based on observation, interview and record review, the facility failed to provide reasonable accommodations of needs for four residents (Resident #4, #12, #14 and #15) in a review of 16 sampled residents, when staff failed to identify the needs of two visually impaired residents (Resident #4 and #12), and did not provide water routinely for Resident #14 and #15. The facility census was 86. Review of the facility policy, Accommodation of Needs, revised January 2020, showed the following: -The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe, independent functioning, dignity and well-being; -The resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; -The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment,…

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 Document under event id WVYK12 Based on observation, interview and record review the facility failed to update a plan of care consistent with resident specific conditions, needs and risks for three residents (Resident #2, #4 and #13) in a review of 16 sampled residents. The facility census was 86. Review of the facility policy, Using the Care Plan, revised August 2006, showed the following: -The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; -Completed care plans are placed in the resident's chart and/or in a 3-ring binder located at the appropriate nurses' station; -The Nurse Supervisor uses the care plan to complete the certified nurse assistant (CNA's) daily/weekly work assignment sheets and/or flow sheets; -CNA's are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met 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 Document under event id WVYK12 Based on observation, interview and record review, the facility failed to ensure staff provided five residents (Resident #6, #3 #12, #10 and #4) of 16 sampled residents, that were unable to complete their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 86. Review of the facility policy Activities of Daily Living (ADLs), Supporting, dated March 2018, showed the following; -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care), mobility (transfer 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 Document under event id WVYK12 Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of four residents, in a review of 16 sampled residents, when they failed to provide regular baths or showers and did not respond to resident call lights in a timely manner for four residents (Resident #4, #9, #3 and #10) resulting in the resident's toileting needs not being met and episodes of incontinence. The facility census was 86. Review of the facility policy, Answering the Call Light, dated March 2021, showed the following: -The purpose of this procedure is to ensure timely responses to the resident's requests and needs; -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident; -Some residents may not be able to use their call light. Be sure to check these residents frequently; -When answering from the call light station, turn off the signal light; -If the resident needs assistance, indicate 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.

Document under event ID WVYK12 Based on observation and interview, the facility failed to ensure food was served at a safe appetizing temperature. This affected five residents (Residents #4, #7, #9, #10 and #16) in a review of 16 sampled residents. The facility census was 86. Review of the facility policy, Assistance with Meals, dated March 2022, showed the following: -For residents confined to bed, the food services department will deliver food carts to appropriate areas, nursing staff will prepare residents for eating and the nursing staff and/or feeding assistants will take food trays into residents' rooms; -Hot foods shall be held at a temperature of 135 degrees F or above until served. Cold foods shall be held at 41 degrees F or below until served. Nursing and dietary services will establish procedures such that delivery of food to serving areas accommodates this requirement; -The policy did not have any guidance for reheating resident food. 1. Observation of the meal times posted in the front dining room showed breakfast was served at 8:00 A.M., lunch at 12:00 P.M. and supper…

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 resident and staff testing for COVID-19 (coronavirus disease, caused by the SARS-CoV-2 virus) was completed according to facility policy for COVID-19 during an outbreak. The facility failed to ensure staff changed gloves and washed hands as indicated during the provision of care for three residents (Residents #2, #9 and #13) in a review of 16 sampled residents. The facility failed to ensure use of proper personal protective equipment (PPE) when staff entered COVID-19 positive rooms and failed to discard of trash from isolation rooms appropriately. The facility census was 86. 1. Review of the facility policy, Coronavirus Disease (COVID-19) - Testing Residents, dated May 2023, showed the following: -Residents are tested for the SARS-CoV-2 virus to detect the presence of current infections and to help prevent the transmission of COVID-19 in the facility; -Asymptomatic residents with close contact with someone with SARS-CoV-2 infection…

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 reasonable accommodations of needs for four residents (Resident #4, #12, #14 and #15) in a review of 16 sampled residents, when staff failed to identify the needs of two visually impaired residents (Resident #4 and #12), and did not provide water routinely for Resident #14 and #15. The facility census was 86. Review of the facility policy, Accommodation of Needs, revised January 2020, showed the following: -The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe, independent functioning, dignity and well-being; -The resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; -The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission…

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 update a plan of care consistent with resident specific conditions, needs and risks for three residents (Resident #2, #4 and #13) in a review of 16 sampled residents. The facility census was 86. Review of the facility policy, Using the Care Plan, revised August 2006, showed the following: -The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; -Completed care plans are placed in the resident's chart and/or in a 3-ring binder located at the appropriate nurses' station; -The Nurse Supervisor uses the care plan to complete the certified nurse assistant (CNA's) daily/weekly work assignment sheets and/or flow sheets; -CNA's are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been…

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 deficiency is uncorrected. For previous examples, see the Statement of Deficiency dated 11/15/23. Based on interview and record review, the facility failed to follow professional standards of practice for 13 of 23 sampled residents (Resident #1, #3, #6, #7, #8, #10, #12, #14, #16, #17, #18, #19, and #20), when staff failed to administer medications as ordered by the physician. The facility failed to ensure one resident (Resident #20) received the correct medications when staff administered another resident's (Resident #10) morning medications. The facility also failed to ensure staff administered prescribed controlled substance medications to three residents (Resident #6, #10, and #8). The facility census was 74. Review of the facility policy Administering Medications, dated April 2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions; -Medications…

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 establish restorative nursing programs that included specific goals and objectives that included the frequency the program was to be provided and failed to ensure staff provided restorative nursing therapy for three residents (Residents #4, #8 and #18), in a review of 18 sampled residents, who were unable to perform their own activities of daily living (ADLs) due to disease processes that affected their daily routines. The facility census was 71. Review of the facility policy, Restorative Nursing Services, dated July 2017, showed the following: -Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services; -Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care; -Restorative goals 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 staff provided five residents (Resident #6, #3 #12, #10 and #4) of 16 sampled residents, that were unable to complete their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 86. Review of the facility policy Activities of Daily Living (ADLs), Supporting, dated March 2018, showed the following; -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care), mobility (transfer and ambulation, including walking),…

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 provide sufficient nursing staff to meet residents' needs for six residents (Residents #2, #12, #1, #15, #11 and #14), in a review of 18 sampled residents, when family members had to assist with the residents' personal care needs and pass meal trays. Staff took 30 minutes or longer to answer resident call lights. Staff were unable to assist residents out of bed who required assistance of two staff with a mechanical lift. The facility also failed to provide sufficient staff for residents to receive restorative nursing services due to the restorative Certified Nurse Aide (CNA) being pulled from his/her duties to work the floor and helping with shipments on Fridays. The facility census was 71. Review of the facility Staffing policy, dated October 2017, showed the following: -The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment; -Licensed nurses and certified nursing assistants…

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 nursing assistants (NAs) demonstrated competency in skills and techniques necessary to care for the residents. Those competencies included transfers, charting, equipment and safety, infection control, bathing, hygiene, perineal care, care plans, and reporting incidents. The failure involved 20 NAs who provided direct resident care, with start dates of 4/4/23 through 8/22/23. The facility census was 71. Review of the facility Staffing policy, dated October 2017, showed the following: -The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment; -Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services; -Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Review of the facility's undated certified nursing…

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

Based on observation and interview, the facility failed to ensure food was served at a safe appetizing temperature. This affected five residents (Residents #4, #7, #9, #10 and #16) in a review of 16 sampled residents. The facility census was 86. Review of the facility policy, Assistance with Meals, dated March 2022, showed the following: -For residents confined to bed, the food services department will deliver food carts to appropriate areas, nursing staff will prepare residents for eating and the nursing staff and/or feeding assistants will take food trays into residents' rooms; -Hot foods shall be held at a temperature of 135 degrees F or above until served. Cold foods shall be held at 41 degrees F or below until served. Nursing and dietary services will establish procedures such that delivery of food to serving areas accommodates this requirement; -The policy did not have any guidance for reheating resident food. 1. Observation of the meal times posted in the front dining room showed breakfast was served at 8:00 A.M., lunch at 12:00 P.M. and supper at 5:00 P.M. Observation on…

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 23. Review of Resident #24's annual MDS, dated [DATE], showed the following: -Cognition intact; -Required physical assistance from two staff for transfers; -Required physical assistance from one staff for toilet use, personal hygiene and bathing. Review of the facility's call light log showed the following: -On 4/02/22, the resident activated the call light at 6:06 P.M. Staff answered the call light 83 minutes later; -On 4/03/22, the resident activated the call light at 10:00 P.M. The call light timed out at 99 minutes; -On 4/04/22, the resident activated the call light at 5:42 A.M. Staff answered the call light 58 later. During interviews on 4/03/22 at 3:29 P.M. and on 4/4/22 at 9:55 A.M., the resident said the following: -He/She has to have help with ADLs and depends on staff to provide his/her care; -It can take staff an hour or more to answer his/her call light; -He/She has pushed the call light and waited hours for staff to answer it, laying in feces the entire time; -Staffing has not been good on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage, other than the Director of Nursing (DON), eight consecutive hours per day seven days per week when the average daily census was greater than 60 residents. The facility census was 71. Review of the facility policy titled, Staffing, revised October 2017 showed the following: -Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment; -Policy Interpretation and Implementation: 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services; 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care; -The facility policy did not specifically address RN coverage. Review of a facility policy titled,…

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 the freezers, refrigerators, and the dishwasher were free of debris buildup, failed to ensure the floors around the refrigerator units were clean, and the floor under the clean plate cart was free of standing water. The facility census was 71. Review of Cleaning Rotation policy, dated 2016, showed the following: -Equipment and utensils will be cleaned according to the following guidelines or manufacturer's instructions; -Items cleaned after each use: can opener, small food preparation, slicer, kettles and utensils, mixers, cutting boards, worktables and counters, beverage table, coffee urns, pots and pans, dishes, dining room table and chairs; -Items cleaned daily: stove top, grill, kitchen and dining room floors, kitchen towels and cloths, toaster, microwave oven, mop and buckets, steam table, hand washing sink, food carts, pot and pan sink, exterior of large appliances; -Items cleaned weekly: hoods, filters, trash barrels, garbage disposals, coffee machine, storerooms, drawers, cleaning closet,…

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 six residents (Resident #9, #12, #16, #29, #54 and #61) in a review of 20 sampled residents and four additional residents (Resident #43, #30, #68 and #78) were treated in a manner to maintain dignity and respect. Resident #54's urinary catheter (tube leading from the urinary bladder to the outside to drain urine) drainage bag was on the floor by the resident's bed and not covered or placed in a dignity bag or with a cover, exposing the bag and urine from the resident's open door. Further observation showed residents were served meals in Styrofoam containers, Styrofoam beverage glasses and with plastic silverware during the survey process. Residents complained that the Styrofoam and plastic use made foods cool quicker and were difficult to use and not homelike. Staff spoke and interacted with two residents, (Resident #29 and #61 in a belittling and disrespectful manner. The facility census was 71. Review of the facility policy,…

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 respond to concerns raised by multiple residents attending the resident council meetings. The facility failed to adequately act upon and provide feedback to the residents regarding their concerns. The facility census was 71. Review of the facility Resident Council policy revised 2/2021 showed the following: Policy Statement: The facility supports residents' rights to organize and participate in the resident council; 1. The purpose of the resident council is to provide a forum for: a. residents, families and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; c. consensus building and communication between residents and facility staff; d. disseminating information and gathering feedback from interested residents. 1. During resident council meeting on 4/5/22 at 11:15 A.M. residents said the following: -Resident #38 said the group was hoping the administrator would meet with them to discuss concerns; -Resident #38 said the group does not get…

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 safe, clean and comfortable environment by failing to ensure residents' rooms and living spaces were clean and in good repair. The facility census was 71. 1. Observation on 04/04/22 between 10:15 A.M. and 4:45 P.M. during the life safety code tour of the facility showed the following: -In resident room [ROOM NUMBER], there was a ¾ inch black ring around the entire base of the toilet; -In resident room [ROOM NUMBER], the hose beside the toilet was leaking water into a trash can; -In resident room [ROOM NUMBER], there were several scuff marks on the wall behind both beds; -In resident room [ROOM NUMBER], there were several scuff marks on the wall behind bed two; -In resident room [ROOM NUMBER], there was a ¼ inch black ring around the entire base of the toilet; -In resident room [ROOM NUMBER], there was a two foot by three inch hole in the wall by bed one; -In resident room [ROOM NUMBER], half of the floor was covered with a brown…

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 develop a plan of care consistent with resident's specific conditions, needs and risks to provide effective person centered care for four residents (Resident #29, #61 and #64) in a review of 20 sampled residents. The facility census was 71. Review of the facility policy, Comprehensive Person-Centered Care Plans, revised December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; 8. The comprehensive, person-centered care play will: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his other rights,…

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 update interventions in the resident's care plan to reflect current care needs for three residents (Resident #16, #39, and #54), in a review of 20 sampled residents. The facility census was 71. Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to met the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The comprehensive care plan is developed within seven days of the completion of the required comprehensive assessment; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents'…

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 staff provided bathing and hygiene needs for three residents (Residents #57, #61, and #64), who were unable to perform their own activities of daily living (ADLs), in a review of 20 sampled residents. The facility census was 71. Review of the facility policy, Supporting Activities of Daily Living (ADLs), revised March 2018, showed the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Residents will be provided with care, treatment and services to ensure their ADL's do no diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADL's are unavoidable; -Appropriate care and services will be provided for resident who are unable to carry out ADL'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 implement their policy addressing cardiopulmonary resuscitation (CPR) requirements for staff. The facility failed to ensure there was an adequate number of staff present at all times who were properly trained and/or certified in CPR for Healthcare Providers to be able to provide CPR until emergency services arrived. The facility had no system to ensure staff were certified in CPR for Healthcare Providers to include a hands-on and in-person skills assessment. The facility failed to ensure they had a system to monitor the medical record to ensure it accurately and consistently indicated the resident's code status for two residents (Resident #39 and Resident #60), in a review of 20 sampled residents and for two additional residents (Resident #43 and Resident #73 ). The facility census was 71. Review of the facility policy Emergency Procedure-CPR revised [DATE] showed the following: Policy statement: Personnel have completed training on the initiation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development and promote healing of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for four residents (Residents #12, #26, #54, and #64), in a review of 20 sampled residents. The facility failed to implement a system to ensure low air loss mattresses, utilized for two residents with pressure ulcers (Residents #12 and #54), were maintained on the correct weight setting to promote healing, and failed to timely reposition two residents (Residents #26 and #64), who were identified as a risk for pressure ulcers, as directed per facility policy to prevent the potential development of pressure ulcers. The facility census was 71. Review of the facility policy, Prevention of Pressure Injuries, revised April 2020, showed the following: -Keep the skin clean and hydrated; -Clean promptly after episodes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide restorative services to assist three residents (Resident #12, #24, and #26) in a review of 20 sampled residents, with mobility and/or limited range of motion, to attain or maintain their highest level of functioning when the restorative aide was pulled to fill certified nursing assistant (CNA) duties. The facility census is 71. Review of the facility policy titled, Restorative Nursing Services, revised July 2017, showed the following: -Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Policy Interpretation and Implementation: 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services ( e.g., physical, occupational or speech therapies); 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative 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, the facility failed to ensure staff used proper technique during gait belt (canvas belt placed around the resident's waist to assist with ambulation and transfer) transfers for one resident (Resident #39) of 20 sampled residents and one additional resident (Resident #8). Staff used Resident #39's pant waist and underarm during transfers and staff transferred Resident #8 with assist of one when the resident's knees were bent and he/she was unable to fully bear weight. The facility census was 71. Review of the facility policy Safe Lifting and Movement of Residents revised July 2017 showed the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to life and move residents; 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; 2. Manual lifting of…

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

Based on observation, interview, and record review, the facility failed to ensure inventories of schedule II controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) and schedule III through IV controlled substance medication, were reconciled by at least two qualified staff to ensure accountability. Further review showed the Director of Nursing (DON) was storing alprazolam, a schedule IV narcotic controlled substance, in his office with no accountability. The facility census was 71. Review of the facility policy, Storage of Medications, revised April 2019, showed access to controlled medications was limited to authorized personnel. Personnel access to controlled medications \was recorded. Review of a facility policy, titled Controlled Substances, revised April 2019, showed the following: -Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications; -Policy Interpretation…

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 one resident's, (Resident #9) Schedule IV narcotic controlled substance anxiety medication was kept in a locked compartment and accounted for when the medication was removed from the resident's room and stored in the Director of Nursing's (DON)'s office. Observation showed the facility failed to keep medication carts locked or attended in open areas accessible to residents and staff prepared and left medications in a resident's room. The facility also failed to remove expired medication from the 100/200 unit medication room. The facility census was 71. Review of the facility policy, Storage of Medications, revised April 2019, showed the following: -Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner; -Policy Interpretation and Implementation: Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls; -Schedule II-V controlled medications are stored in separately locked, permanently affixed…

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 staff prepared and served food at a safe and appetizing temperature. The facility census was 71. Review of the facility's Food and Nutrition Services policy, revised April 2019, showed the following: -Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature; -If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued; -Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than two hours will be discarded. Review of the facility's Serving Temperatures for Hot and Cold Foods, dated 2016, showed the following: -Foods will be served at the following temperatures to ensure a safe and appetizing dining experience; -The minimum serving temperatures do not reflect the required…

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 offer residents a daily bedtime snack. The facility census was 71. Review of the facility's policy, Serving Snacks (Between Meal and Bedtime), revised September 2010), showed the following: -The purpose of this procedure is to provide the resident with adequate nutrition; -Review the resident's care plan and provide for any special needs of the resident; -Place the snack on the over bed table or serving area; -Assist the resident as necessary; -Record the date and time the snack was served; -If the resident refused the snack, the reason(s) why and the intervention taken; -Report any problems or complaints made by the resident related to the snack. 1. During group interview on 4/5/22 at 11:15 A.M. five of five residents said they do not get snacks at bedtime. No one comes to offer bedtime snacks. They would take a bedtime snack if it was offered. During an interview on 4/4/22 at 12:50 P.M., Resident #61 said he/she only received snacks brought in by his/her family member. During an interview on 4/4/22 at 2:42 P.M., 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, the facility failed to use appropriate infection control procedures for hand hygiene and changing gloves, to prevent the spread of bacteria or other infectious causing contaminants for one resident (Resident #57) in a review of 20 sampled residents and two additional residents (Resident #45 and #78). Further observation showed the facility failed to prevent contamination of a nasal cannula (a plastic tube device for delivering oxygen by way of two small prongs that are inserted into the nares) for one resident (Resident #54). The facility failed to ensure two staff exempted from receiving COVID (Coronavirus) vaccines (Nurse Aide (NA) M and NA O), wore N95 respirators as required. The facility census was 71. Review of the facility policy, Handwashing/Hand Hygiene, revised 2001, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infection; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to vaccinate eligible residents with the pneumococcal vaccine as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines, unless the resident had previously received the vaccine, refused, or had a medical contraindication present for five residents (Residents #12, #16, #24,#37, and #54,) in a review of 20 sampled residents. The facility census was 71. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time Table for Adults, dated 4/1/22, showed the following: -CDC recommends pneumococcal vaccination for: *Adults [AGE] years old and older; * Adults 19 through [AGE] years old with certain underlying medical conditions or other risk factors (*considered an immunocompromising condition) including alcoholism, cerebrospinal fluid leak, chronic heart/liver/lung disease, chronic renal failure*, cigarette smoking, cochlear implant, congenital or acquired asplenia*, congenital or acquired…

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 inspections of bed frames, mattresses, bed rails and assist bars as part of a regular maintenance program to identify areas of possible entrapment for two residents (Resident #55 and #61) in a review of 20 sampled residents and for one additional resident (Resident #30). The facility census was 71. Review of the facility's Proper Use of Side Rails or Assist Bars Policy, dated December 2016, showed the following: -Purpose: The purposes of these guidelines are to ensure the safe use of side rails or assist bars as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; - An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review to ensure the bed's dimensions are appropriate for the resident's size and weight; -When side rail…

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 maintain the wireless call light system to ensure staff carried functioning pagers to alert them to residents' calls for staff assistance. Review of the call light response time log showed staff did not respond to call lights timely with resident's experiencing extensive wait times for staff. The facility census was 71. Review of a facility, undated, policy titled Wireless Nurse Call System, showed the following: -Purpose: The Wireless Nurse Call system is utilized to ensure residents have the ability to alert staff of their needs and staff respond in a timely manner; -Policy: Charge nurses are responsible for handing out pagers at the beginning of the shift and collecting at the end of the shift. Any extra pagers and replacement batteries are to be kept at the nurses station; -How residents initiate call - Each resident will have a nurse call button (located in each resident room and bathroom) to push if they need to alert staff of their needs. An alert is also initiated if a resident with a security…

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 the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one resident (Resident #11), in a review of 20 sampled residents. The facility failed to ensure the resident had an ordered sleep study. The facility census was 71. 1. Review of Resident #11's face sheet showed the following: He/She was admitted to the facility on [DATE]; -Diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture) and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Review of the resident's physician's orders dated 10/6/21 showed an order for a sleep study for CPAP (continuous positive airway pressure/a common treatment for obstructive sleep apnea) due to sleep apnea. Review of the resident's social service progress notes dated 11/10/21…

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 staff utilized proper handwashing and gloving techniques between clean and dirty tasks, and failed to ensure kitchen trash cans were covered when not in use. The facility census was 92. 1. Observation on 9/4/19 between 12:02 P.M. and 12:12 P.M. showed Dietary Staff U removed bags of trash from trash cans and left the kitchen with the trash bags. He/She re-entered the kitchen, did not wash his/her hands and placed new clean trash bags inside the trash cans. Dietary Staff U then placed dirty dishes into a rack near the dish machine. He/She slid the rack inside the machine, closed the door to start the dish machine, and sprayed down the dirty dish area with the sprayer nozzle. Without washing his/her hands, Dietary Staff U began removing clean dishes from the rack and carrying them across the kitchen. He/She placed the clean utensils, cups and pitchers on the storage racks. Observation on 9/4/19 at 12:17 P.M. showed the dietary supervisor wore gloves and began placing dirty dishware, the food processor…

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 resident dignity was maintained for five sampled residents (Resident #3, #7, #20, #33, and #46) of 21 sampled residents when staff failed to provide privacy during personal care. The facility census was 92. 1. Review of the facility's Quality of Life-Dignity Policy, revised date August 2009, showed the following: -Residents shall he treated with dignity and respect at all times. -Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 2. Review of Resident #46's annual, dated 7/4/19, showed the following: -The resident had severe cognitive impairment; -The resident required extensive assistance from one staff member to transfer, dress, toilet, bathe and bed mobility; -He/She did not ambulate; -The resident was frequently incontinent of bladder; -The resident was occasionally incontinent of bowel. Review of the resident's care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff provided five of 21 sampled residents (Resident #46, #3, #20, #55, and #294 ) and three additional residents (Resident #33, #52 and #7) that were unable to do their own Activities of Daily Living (ADL's), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 92. 1. Review of the facility's policy for perineal care, undated, showed the following: -The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Equipment and supplies necessary for performing the procedure included towels, disposable wipes/washcloths, and personal protective equipment (gloves, gowns, mask, etc.); -Expose the perineal area; -With a disposable wipe, wipe the perineal area from front to back and from the center to the thighs; -Fold the wipe to use a clean section for each stroke;…

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 implement interventions to prevent accidents for one resident (Resident #294) in a review of 21 sampled residents and for two additional residents (Resident #7 and #85) and one closed record (Resident #95). The facility census was 92. 1. Review of the facility policy Falls and Fall Risk, Managing, dated 12/07 showed: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize (i.e., to try one or a few at a time, rather than many at once.) Examples of initial approaches might include exercise and balance training or 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.

Based on observation, interview, and record review, the facility failed to ensure staff served the correct portion sizes according to the dietary spreadsheet menu for residents on physician ordered pureed diets. The facility census was 92. 1. Record review of the facility policy, Purpose and Function of the Department, dated 2011, showed the following procedure: -To provide a nutritious, palatable, well balanced meals that meet the daily nutritional needs of residents; -To comply with physician diet orders for all residents, including those on therapeutic diets and those with special nutritional needs. 2. Record review of the Meal Service Observation and Procedures, dated 8/28/19, completed by the facility's Consultant Dietician, showed the following Procedure Observed, Correction Status and Recommendations/Comments: -Service: Scoops Correct-Needs Correction. Residents received 1 ounce meat on their taco salad. Asked cook why he/she used 1 ounce scoop. The cook said out of many scoops and decided to use his/her own judgement. This dietician went back to kitchen, plenty of 4-ounce…

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 the entree for supper on 9/3/19 was prepared according to the recipe for all residents on a regular, mechanical soft and pureed diets to conserve nutritive value, flavor and appearance. The facility census was 92. 1. Review of the facility's policy, Standardized Recipes, dated 2011, showed standardized recipes will be used for all menu items, including pureed and therapeutic diets. Review of the facility policy, Pureed Food Preparation, dated 2011, showed the following: -Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability and maximum nutritional value; -Standardized recipes will be used to prepare all pureed foods. The recipes will be adjusted according to the number of pureed diets needed, indicating seasoning and technique to ensure the highest quality; -Recipes will not use water to thin pureed foods. Only broth, milk, juice, gravy, margarine or another appropriate condiment that preserves flavor shall be used; -The flavor of pureed foods will be…

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 residents with a physician's order for a mechanical soft diet and a pureed diet received food items with the proper texture. The facility census was 92. 1. Review of the facility's Diet Roster-By Diet, dated 9/3/19, showed 21 residents with a physician order for a mechanical soft diet and eight residents with a physician order for a pureed diet. 2. Review of the facility policy, Pureed Food Preparation, dated 2011, showed pureed foods will be the consistency of applesauce or smooth, mashed potatoes. 3. Review of the Diet Spreadsheet (Week 1 Day 3) for supper on 9/3/19 showed residents on a pureed diet should receive a #6 (2/3 cup) serving of spaghetti and meatballs. Observation and interview on 9/3/19 at 3:28 P.M. showed Dietary Staff S prepared the pureed meatballs. He/She mixed two large chunks of meatloaf, and an unmeasured amount of tomato sauce and tap water in the food processor. The mixture was lumpy and chunky in appearance. Dietary Staff S placed the pans, containing the mixture, in the oven.…

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 nursing staff washed their hands and changed soiled gloves after each direct care contact and when indicated by professional practices during personal care for six Residents (Resident #46, #20, #3, #55, #87 and #294) of 21 sampled residents and for three additional residents (Resident #7, #33 and #52). The facility census was 92. 1. Review of the facility policy Handwashing/Hand Hygiene dated July 2017 showed the following: -The facility considered hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands were visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol based hand rub or alternatively soap and water before and after coming on duty, direct contact with residents, handling an invasive device, eating or handling food, assisting a resident with meals and when entering isolation precaution settings; -Use an alcohol based hand rub 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 the facility fail to follow physician orders as written for one sampled resident (Resident #55) in a sample of 21 sampled residents. The facility census was 21 1. Review of the facility policy Physician Orders dated 2/14 showed all physician orders must be received, recorded and implemented and signed properly. All physician orders must be in writing (or in electronic orders) and signed/dated by the practitioner ordering the service. Medication orders and treatments will be administered by nursing personnel as soon as the order has been received based upon next start date and time available per the order. All orders must be charted and made a part of the resident's medical record. Any conflict in treatment or medication must be brought to the attention of the ordering physician, Attending Physician, and the Director of Nursing Services prior to the performance or administration of such treatment or medication. 2. Review of Resident #55's Annual Minimum Data Set…

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 appropriate care, treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) for two residents (Resident #87 and #294), with an indwelling urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine) of 21 sampled residents The facility identified two residents with indwelling urinary catheters. The facility census was 92. 1. Review of the facility's undated policy Perineal Care showed the following: -The purpose was to provide cleanliness and comfort to the resident, prevent infections and skin irritation and observe the residents skin condition; -Wash hands and apply gloves; -Remove as many of the disposable wipes as needed; -Wash a female resident's perineal area, wiping from front to back. Gently wash the juncture of the indwelling urinary catheter from the urethra down the catheter about three inches. Wash the perineum moving…

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 resident one resident, (Resident #87) who received nutrition by enteral means (involving or passing through the intestine, either naturally via the mouth and esophagus, or through an artificial opening), received the appropriate treatment to prevent complications of enteral feeding in a review of 21 sampled residents. The facility identified two residents with feeding tubes. The facility census was 92. 1. Review of the facility policy Checking Gastric Residual Volume (GRV) dated March 2015 showed the following: -The purpose was to assess tolerance of enteral feeding and minimize the potential for aspiration; -Verify a physician's order for the procedure; -Review the resident's care plan and provide for any special needs of the resident; -Evaluate resident s receiving enteral nutrition for the risk of aspiration; -Check the position of the feeding tube before initiation of each feeding; -Check the GRV with at least a 60 milliliter…

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 food that accommodated resident preferences for one resident (Resident #83), and failed to ensure residents on a mechanical soft or pureed diet were given the opportunity to request or select food items of their preference, as residents on a regular consistency diet, during meals. The facility census was 92. 1. Review of Resident #83's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 8/9/19, showed the following: -Cognitively intact; -Independent with set-up only for eating; -Mechanically altered diet. Review of the resident's physician order sheet, dated September 2019, showed the following: -Diagnoses included dysphagia (swallowing disorder); -Pureed diet with honey thickened liquids; -No sausage. Review of the resident's care plan, last revised 8/1/19, showed the following: -Pureed diet with honey thickened liquids; -No sausage with breakfast; -Give pureed toast. Observation on 9/4/19 at 8:50 A.M. showed staff served the resident ground…

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 ensure one resident (Resident #56) had fluids available to drink as he/she ate his/her meal. The facility census was 92. Observation on 9/5/19 at 12:10 P.M. showed the following: -Resident #56 sat in the division II dining room. The resident had two empty drinking glasses in front of him/her; -At 12:20 P.M., staff delivered the resident's tray which contained a divided plate with a pureed diet. Staff did not offer to refill the resident's drink glasses; -At 12:25 P.M., the resident picked up his/her empty glass, tipped it to his/her mouth and attempted to get a drink; -At 12:34 P.M., Resident #79 arrived to the same table (sat directly across from Resident #56), raised his/her hand and asked staff for coffee and tea; -At 12:34 P.M., staff delivered dessert to the residents but did not offer fluids to the resident; -At 12:36 P.M., staff delivered drinks to Resident #79 but did not offer fluids to Resident #56; -At 12:40 P.M., the resident again picked up an empty glass and attempted to get a drink; -At 12:50 P.M., 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, the facility failed to ensure a garbage dumpster outside the facility was kept closed to prevent access to rodents and pests. The facility census was 92. 1. Record review of the facility policy, Garbage and Rubbish Disposal, dated 2011, showed outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. 2. Observation on 9/03/19 at 12:47 P.M. showed a blue dumpster, located outside the facility, was overflowing with trash bags. The dumpster lid was open and the garbage container was not covered. Observations on 9/4/19 at 8:10 A.M. and 1:55 P.M. showed the blue dumpster contained garbage bags. The dumpster lid was open. During an interview on 9/5/19 at 11:00 A.M., the dietary supervisor said the dishwasher aide was responsible for emptying trash cans and taking the trash bags outside to the dumpster. Other departments and staff members also use the dumpster. The lids are usually closed, but sometimes it's overflowing with trash and staff are not able to close the lid. During an interview on 9/5/19 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.