Douglas County Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 12-006.09(H)(vi)(3)(g) Based on observation, interview and record review, the facility failed to obtain and implement orders for a non-invasive ventilator including settings and daily, weekly, and monthly cleaning for 1 (Resident 55) of 4 sampled residents. The facility census was 235. The findings are: Record review of Resident 55's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 04-18-2025 revealed the facility staff assessed the following about the resident: -The resident was admitted to the facility on [DATE]. -A Brief Interview of Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) was scored as a 14/15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -The resident required extensive assistance with lower body dressing, bed mobility, and transfers. -The resident required total assistance with toileting and bathing. -The resident had diagnoses of congestive heart failure…

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

Based on record review and interview, the facility failed to assess for pain prior to administering scheduled pain medication and failed to monitor for the effectiveness of pain medication for 1 (Resident 19) of 2 sampled residents. The facility had a census of 240. Findings are: A record review of the facility's Pain Management Policy which was last modified on 3/20/2025 revealed the following policy statement: -A resident will be assessed for the presence/absence of pain on admission, at least quarterly at the time of the MDS (Minimum Data Set - a federally mandated standardized assessment tool used in nursing homes to gather information about resident's health, functional status, and preferences) assessment and when there is a change in the resident's condition and any time a resident is receiving pain medication. A record review of Resident 19's physicians orders revealed Resident 19 has an order for scheduled Tramadol HCL (a medication used to relieve moderate to moderately severe pain) 50 MG (milligrams - a unit of measurement) tablet. 1 tablet three times a day for pain. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure trauma survivors received trauma-informed care to eliminate triggers that may cause re-traumatization for 1 (Resident 135) of 2 sampled residents. The facility census was 240. Findings are: A record review of Resident 135's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed Resident 135 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, anxiety disorder and post-traumatic stress disorder (PTSD). Resident 135 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 10/15. The MDS manual identified a score of 8-12 as having moderately impaired cognition. A record review of progress notes written by Licensed Practical Nurse (LPN)-I on 05/02/2025 and 05/03/2025 revealed Resident 135 was confrontational with cares and…

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

Based on record reviews and interviews, the facility failed to ensure 3 (Resident 218, 135, 226) of 7 residents had a physician conduct a face-to-face visit within the first 30 days after admission. The facility census was 240. Findings are: A. A record review of Resident 218's admission record revealed an admission date of 07/30/2024. A review of Resident 218's records revealed there was no evidence of a physician visit within the first 30 or 60 days after admission. Record review revealed Resident 218 was seen by a nurse practitioner (NP) on 08/09/2024 to establish care and on 09/20/24 for recertification. B. A record review of Resident 135's admission record revealed an admission date of 03/11/2025. A review of Resident 135's records revealed there was no evidence of a physician visit within the first 30 days after admission. A record review revealed Resident 135 was seen by an NP on 03/11/2025 for admission history and physical. C. A record review of Resident 226's admission record revealed an admission date of 04/15/2025. A review of Resident 226's records revealed there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B) & 1-005.06 Based on observation, interview and record review the facility failed to secure a catheter bag for 1 (Resident 221) of 2 residents and failed to secure oxygen tubing with cannula for 1 (Resident 108) of 5 residents sampled in a manner to prevent the potential for cross contamination. The facility census was 240. The findings are: A. Record review of Resident 221's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-12-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was not conducted because Resident 221 was not able to complete the interview. -The resident required extensive assistance with dressing and personal hygiene. -The resident required total assistance with bed mobility, toileting and bathing. -The resident had an indwelling urinary catheter (a tube inserted into the bladder to collect urine). An observation on 05-07-2025 at 9:10 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04(f)(i)(5) Based on observation, record review and interview; the facility failed to ensure follow up was completed with the physician to obtain x-rays after complaints of pain were made by Resident 1 and failed to ensure x-ray recommendations were followed timely for Resident 1. X-rays showed that Resident 1 sustained a fracture of the right shoulder. The facility census was 239. Findings are: Record review of Resident 1's Face Sheet revealed a admission date of 4/5/19 with diagnoses that included restlessness and agitation, altered mental status, schizophrenia, psychosis and mood affective disorder. Record review of Resident 1's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 4/30/24 revealed a BIMS (Brief interview for mental status, a brief screener that aids in detecting cognitive impairment) score of 15, which indicated that Resident 1 was cognitively intact. The MDS showed that resident 1 was independent…

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 implement a care planned intervention for 1 (Resident #2) of 6 residents whose care plans were reviewed. Specifically, following an incident on 04/22/2023 involving Resident #2 and another resident, the facility implemented a new intervention consisting of a magnetic barrier attached to Resident #2's door frame to deter other residents from entering Resident #2's room. This intervention was never discontinued, but the barrier was removed, and additional resident to resident altercations involving Resident #2 and Resident #3 occurred on 10/17/2023 and 11/22/2023, when Resident #3 entered Resident #2's room. Findings included: The facility's policy titled, Interdisciplinary Plan of Care, reviewed on 04/23/2024, indicated, Members of the Interdisciplinary Team are responsible for updating the plan of care, as indicated, as the resident's status changes or as other problems/needs are identified. Interdisciplinary Team members will review and evaluate the plan of care to make recommendations and revisions as needed. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure staff stored foods for residents in a sanitary manner. Specifically, staff failed to label and date resident foods brought in by visitors, clear the nourishment refrigerators of spoiled foods, and maintain the temperature logs for the nourishment refrigerators. This had the potential to affect 153 residents who resided in 6 neighborhoods (Wind Song Way, Field of Dreams, [NAME] Way, Tranquility Road, Sunshine Gardens, and Safe Harbor) of 10 total neighborhoods in the facility. Findings included: Review of a facility policy titled, Use and Storage of Food Brought in by Family or Visitors, last modified on 10/21/2019, revealed, Policy: It is the right of the residents of this facility to have food brought in by family or other visitors. However, the food must be handled in a way to ensure the safety of the resident. The policy specified, 2. All food items that are already prepared by the family or visitor brought in must 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to invite 1 (Resident #45) of 39 sampled residents whose care plans were reviewed to attend their care conferences. Findings included: A review of a facility policy titled, Interdisciplinary Plan of Care, last modified on 02/03/2021, revealed, Purpose 1. To facilitate an interdisciplinary approach to resident care which is aimed at meeting the many and varied needs of the resident. 2. To promote collaboration of the various disciplines. Procedure The resident's interdisciplinary plan of care is developed and revised through a collaborative effort of an Interdisciplinary Team (IDT), the resident and the resident's guardian/DPOA [durable power of attorney] or representative of his/her choice. The policy further specified, 3. The disciplines discuss their assessments of the resident's needs. The members of the Interdisciplinary Team, the resident, and their family/guardian or representative of his/her choice are encouraged to 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 record review, interviews, and facility policy review, the facility failed to promptly notify a resident's hospice service provider of a change in condition for 1 (Resident #231) of 2 sampled residents reviewed for change in condition. Specifically, Resident #231's hospice and primary care provider were not notified of an abnormal culture and sensitivity (C&S) lab result until a week after it was reported to the facility. As a result of this delayed notification, the hospice provider did not order an antibiotic to treat Resident #231 until a week after the abnormal C&S lab result was reported to the facility. Findings included: A review of a facility policy titled Guidelines for Physician Notification, last modified by the facility on 09/28/2020, revealed under the section titled Physician Notification, the column titled Next Working Day indicated that physician notification by the next working day was recommended in the guidelines for laboratory tests, including a Urine Culture and Sensitivity revealing > [greater than] 100,000 colony count without any symptoms. Further…

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 observations, interviews, record reviews, and facility policy review, the facility failed to ensure call lights were within reach for 2 (Resident #101 and Resident #487) of 2 residents observed for the use of call lights. Findings included: A review of a facility policy titled Call Lights: Accessibility and Response, last modified by the facility on 04/24/2024, revealed, 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. A. A review of Resident #487's admission Record revealed the facility admitted the resident on 06/23/2023 and readmitted the resident on 04/17/2024. According to the admission Record, the resident had a medical history that included diagnoses of a history of falling and difficulty in walking. A review of an admission Minimum Data Set (MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.), with an Assessment…

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

Based on interviews, record review, and facility policy review, the facility failed to ensure new Level I Preadmission and Resident Reviews (PASRRs) were completed after residents were diagnosed with new mental illness diagnoses and prescribed psychotropic medications for 2 (Resident #12 and Resident #74) of 5 sampled residents reviewed for PASRR requirements. Findings included: A review of a facility policy titled, Pre-admission Screening and Resident Review (PASSR), last modified on 12/12/2018, revealed, With any significant change in status or newly evident or possible serious mental disorder or intellectual disability or related condition, a new PASRR Level I screen will be completed for any resident identified per a Level II screen as requiring specialized services. Any changes will be promptly reported to the State mental health authority or State intellectual disability authority as indicated. A. A review of an admission Record revealed the facility admitted Resident #12 on 06/26/2008. According to the admission Record, the resident had a medical history that included…

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

Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside of 1 (Resident #102) of 20 residents that resided in the Field of Dreams neighborhood, which was a locked behavioral unit. Findings included: A review of an admission Record revealed the facility admitted Resident #102 on 07/10/2023. A review of a quarterly Minimum Data Set (MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.), with an Assessment Reference Date (ARD) of 02/21/2024, revealed Resident #102 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #102's April 2024 Medication Administration Record (MAR) revealed the resident was scheduled to receive the following medications during the 9:00 AM medication pass on 04/22/2024: - allopurinol oral tablet 300 milligrams (mg), one tablet one time a day for prevention of calcium-containing kidney stones; - aspirin delayed release 81 mg tablet, one…

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 observations, interviews, review of medical records, and facility policy review, the facility failed to ensure staff performed hand hygiene and did not touch medications with their bare hands when administering medication for 1 (Resident #160) of 3 residents observed during medication pass. Findings included: A review of a facility policy titled, Hand Hygiene, last modified on 07/14/2023, revealed, 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. A review of the attached Hand Hygiene Table revealed staff should perform hand hygiene with Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred) Between resident contacts and Before preparing or handling medications. A review of an admission Record revealed the facility admitted Resident #160 on 03/21/2018. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety; type two diabetes mellitus;…

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 record review and interview; the facility failed to provide a written investigation to the state agency within the required five working days for 1 (Resident 1) of 3 sampled residents. The facility census was 231. Findings are: Review of the [NAME] County Health Center Abuse/Neglect/Misappropriation/Crime Reporting Form, dated 2/12/24, revealed that the Administrator and Director of Nursing (DON) were notified of an incident that involved Resident 1 on 2/12/24 at 2:30 PM and that the incident was reported to [name] at Adult Protective Services (APS) at an undocumented date and time. Review of the [NAME] County Health Center fax cover sheet dated 2/16/24 and addressed to the state agency included the written investigation called to APS. Interview on 3/5/24 at 12:18 PM, the Assistant Director of Nursing (ADON) revealed that the written investigation had been scanned into a draft folder and then never sent in. The ADON confirmed that the written facility investigation had not been provided to the state…

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.

Licensure reference: 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure glove changes were completed during food preparation and service to prevent potential food borne illness. This has the potential to affect 208 residents who eat meals prepared in the kitchen. The facility had a total census of 216 residents. Findings are: Observations of tray line on 5/15/23 between 11:45 AM-12:03 PM revealed Cook-F wearing gloves to open freezer door to obtain pizza then with same gloves used hands to place sausage on pizza. Cook-F continued with food preparation without changing gloves including handling precook hamburgers and tomato and lettuce for hamburgers. [NAME] F wearing same gloves moved trash can and continued with food preparation including handing ready to eat foods with changing gloves. Observations of tray line on 5/15/23 between 11:45 AM-12:03 PM revealed Cook-G wearing gloves dishing food from steam table on to plates then opening steam table drawer and dishing French fries on to plate with same gloves. Observations of tray line on 5/15/23 at…

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

Licensure Reference Number 175 NAC 12-004.c3a(6) Based on observation, interview, and record review, the facility failed to notify the provider and resident representative of a change in condition for Resident 175. Total facility census was 216. Findings are: Record review of the facility's guidelines for Physician Notification with revision date of 05/26/2022 revealed the facility was to notify the House Supervisor or Nurse Manager of resident condition changes, and the physician should have been notified the next working day of any wound unless they required sutures (stitches). Record review of the facility's Notification of Resident Condition Change/Room Change Policy with a last review date of 11/07/2022 revealed in the event of a significant change in the resident's condition, the resident's family or legal guardian and the House Supervisor would be notified by the licensed nurse on duty. Observation on 05/10/2023 at 4:43 PM revealed Resident 175 was in the dining room reclined in the wheelchair with both socks off and was observed to have brown crusted wounds to the right foot…

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.

Licensure Reference Number 175 NAC 12-006.18B Based on observation and interview, the facility failed to ensure 1 (Resident 129) of 1 sampled resident's water faucet was operational to allow the flow of hot water. Total facility census was 216. Findings are: An observation of Resident 129's room on 05/10/2023 at 04:47 PM revealed no hot water was released when the hot water handle was turned to the on position on the water faucet. An observation of Resident 129's room on 05/11/2023 at 01:00 PM revealed no hot water was released when the hot water handle was turned to the on position on the water faucet. An observation on 05/15/2023 at 07:25 AM revealed hot water lever was still not working on Resident 129's water faucet. In an observation and interview on 05/15/2023 at 11:33 AM, Registered Nurse (RN)-A observed the hot water lever on Resident 129's faucet did not turn on when the handle was turned and confirmed the hot water on the faucet did not work. In an interview on 05/16/2023 at 08:10 AM, Maintenance Director (MD)-D confirmed there was not a work order in the system 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.

Based on record review and interview, the facility failed to reevaluate resident status and provide notice of discharge for 1 [Resident 265] of 1 sampled resident following transfer to the hospital in an emergency status. The facility had a total census of 216 residents. Findings are: Record review of Resident 265's Progress Notes dated 3/31/23 revealed Resident 265 had reported eating 4 or 5 AA batteries, part of a stuffed animal and part of a CD player. Orders were received to send Resident 265 to the emergency room. Bed Hold policy was sent with Resident 265. Record review of Resident 265's Social Services notes dated 4/5/23 as a late entry for 4/4/23 revealed bed hold policy and transfer notice were mailed to guardian. Social Service notes dated 4/6/23 revealed 15 day Medicaid bed hold policy was explained to Resident 265's mother/guardian. Social Service Notes dated 4/10/23 revealed Resident 265's mother/guardian was contact to arrange for pick up of Resident 265's belongings. Record review of Bed Hold Policy Notice dated 3/31/23 revealed Resident or Resident representative had…

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

LICENSURE REFERENCE NUMBER 175 NAC 12-006.14 Based on record review, interview, and observation, the facility failed to ensure Resident 176 received follow up dental services. The facility staff identified a census of 216. Findings are: Interview on 5/10/23 at 2:50 PM with Resident 176 revealed that [gender] had dental x-rays 2 months ago and had not recieved follow up. Resident 176 revealed [gender] wanted teeth removed to get dentures. Observation on 5/10/23 at 2:50 PM revealed that Resident 176 has multiple decayed and broken teeth. Interview on 5/11/23 at 2:00 PM with Social Worker (S.W.-H, someone who assists Resident's with a variety of arrangements and financial services) revealed that information has not been recieved from the dentist. Interview on 5/11/23 at 3:00 PM Nurse manager (N.M.-I, A Registered Nurse that monitor and oversees the Residents on specific units of the facility), verified that there were no other dental visits for Resident 176 since 10/28/22. Record review of Physician consult document dated 10/28/22. The document has a written note on it stating, I…

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 Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene (cleaning) between resident contact. This had the potential to affect 3 residents (Resident 80, 131, and 146). Total facility census was 216. Findings are: Record review of the facility's Hand Hygiene Policy with a last review date of 07/14/2022 revealed staff should perform hand hygiene before touching a resident, after touching a resident, and after contact with body fluids. Observation on 05/10/2023 at 11:50 AM revealed Resident 80 was sitting in the [NAME] Way Dining Room with nasal drainage from Resident 80's nose extending to their legs. Recreational Therapy Aide (RT)-C used a towel to wipe Resident 80's nasal drainage and proceeded to then place RT-C's right hand on Resident 131's back without having performed hand hygiene. Observation on 05/11/2023 at 1:28 PM revealed RT-C was seated in the [NAME] Way Dining Room with RT-C's shoe and sock removed.…

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.