Arbor Glen Center

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to retain health files for staff that were no longer employed with the facility for the timeframe required, for 2 of 20 new employee files reviewed. This deficient practice was evidenced by the following: On 12/1/25 at 10:14 AM, during entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the medical files of the facility's 20 new hire employees since their last recertification survey. On 12/4/25 at 10:18 AM, the surveyor asked the LNHA for additional files for employees that were not given to the surveyor. The LNHA stated that the files were sent to storage if they were no longer employed with the facility and that she was calling to get the files. On 12/8/25 at 11:26 AM, the surveyor interviewed the Nurse Practice Educator (NPE) regarding process for health files. The NPE stated that when the staff member was no longer employed, she gave the file to human resources. On 12/8/25 at 1:00 PM, the surveyor notified the LNHA and…

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

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for soiled linens and waste to decrease the possibility of spreading infection. The deficient practice was observed during tour on 1 of 4 units. This deficient practice was evidenced by the following: On 12/8/25 at 11:17 AM, the surveyor observed with a Registered Nurse Unit Manager (RN/UM) the soiled utility room of Unit #1. The RN/UM stated the designated room was the only soiled utility room on the unit. The room had signage which indicated storage room and was secured with a keypad lock. Upon entering the room, the surveyor accompanied by the RN/UM observed on the front, right side of the room, one covered yellow colored bin with signage indicating only soiled diapers please; a large transport bin with a couple of clear plastic bags containing linen items; and three smaller covered garbage bins including one with signage labeled soiled gowns. The surveyor observed to the left side of the room, storage racks…

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 review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) 2 of 2 dining areas, b.) 1 of 4 unit hallways, and c.) and 2 of 21 sampled residents (Residents #20 and #33) rooms. This deficient practice was evidenced by the following: 1.On 12/2/25 at 11:23 AM, Surveyors #1 (S #1) and Surveyor #2 (S #2) in the presence of the Registered Nurse/Unit Manager (RN/UM) observed the 2nd floor dining (also known as the activity room) area with 10 residents and one activity staff. The surveyors and the RN/UM observed the six heating system inside the grill with dried leaves, plastics, pieces of puzzles, papers, and grayish substances which the RN/UM confirmed that was accumulation of dust and should have been cleaned. At that same time, the surveyors and the RN/UM observed there were multiple boxes of different kinds of puzzles on top of one of the heating system. The RN/UM stated that those different boxes of puzzles that the activity department were being used for residents' should…

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.

Complaint # 406965Based on interviews and record review and review of pertinent facility documentation, the facility failed to ensure that the physician was notified in a timely manner of a resident's change in condition for 1 of 3 residents reviewed for transfer to the hospital (Resident #1). This deficient practice was evidenced by the following:On 11/10/25 at 9:30 AM, the surveyor reviewed Resident #1's closed medical record. A review of Resident #1's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; congestive heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs) chronic obstructive pulmonary disease (aka COPD, a group of lung diseases that cause airflow obstruction and breathing difficulties) and obstructive sleep apnea (a sleep disorder where the airway repeatedly collapses or becomes blocked during sleep, leading to pauses in breathing).A review of Resident #1's electronic Progress Notes (PN) included 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 the interview and review of pertinent facility documentation, the facility failed to have the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) present for one (1) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 111 residents who currently live in the facility. The deficient practice was evidenced by the following: On 8/01/24 at 9:44 AM, the surveyor met with the LNHA and the DON during an Entrance Conference meeting. Both the LNHA and the DON confirmed that day census (total number of residents) of 111 with no bed hold. On 8/01/24 at 12:09 PM, the LNHA provided the last three-quarters of QAPI sign-in sheets and revealed the following: QAPI Attendance: 01/17/24=the Medical Director (MD), DON, and other Interdisciplinary Team (IDT) signed the QAPI Attendance sheet. There was no documented evidence in the sign-in sheet that the LNHA and the Infection Preventionist (IP) attended the meeting. 4/15/24=the LNHA, MD, DON, IP, IDT, and vendor representative signed the QAPI…

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 the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy for one of (1) of two (2) residents, (Resident #82), reviewed for hospitalizations. This deficient practice is evidenced by the following: On 8/01/24 at 10:39 AM, the surveyor observed Resident #82 lying on their bed while watching the television with an indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine). There was an Enhanced Barrier Precaution (EBP) sign outside the door. The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #82. The admission Record (or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (elevated blood pressure), other retention of urine, anemia (low blood…

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 it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for three (3) of 24 residents, Residents #23, 109, and 167, reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. The surveyor reviewed the electronic health record (EHR) of Resident #109 which revealed the following: The admission Record (AR; a summary of important information about the resident) revealed that Resident #109 had diagnoses that included, but were not limited to, spinal stenosis (narrowing of the space around the spinal cord), osteoporosis (a condition which bones become weak and brittle), and hypertension (high blood pressure). The most recent Discharge-Return Not Anticipated (DRNA) MDS assessment, under section A, A2105, Discharge Status it was coded that the resident was discharged to 4. Short-Term General Hospital. A review of progress notes (PN) revealed the resident was discharged…

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 review of pertinent facility documents, it was determined that the facility failed to a.) act upon the recommendations of the Urologist for one (1) of two (2) residents (Resident #82) reviewed for the care of urinary catheter and b.) ensure a resident's medication administration time was adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) for one (1) of one (1) resident (Resident #12), reviewed for dialysis, according to facility's policies and standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life…

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.

Complaint#: NJ#174298 Based on interviews, record review, and review of other pertinent facility-provided documentation, the facility failed to ensure a.) that the resident with injury of unknown origin received treatment and implemented an intervention according to comprehensive assessment and person-centered care plan in accordance with professional standards of practice, and facility's policy and procedure for one (1) of three (3) residents, Resident #165, reviewed for abuse. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized…

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.

Complaint #NJ160835 Based on interview, and record review it was determined that the facility failed to provide care and services consistent with professional standards of clinical practice for a resident with pressure ulcers. This deficient practice was identified in one (1) of four (4) residents, Resident #168, reviewed for pressure ulcer care and prevention. The deficient practice was evidenced by the following: On 8/05/24 at 12:19 PM, the surveyor reviewed the hybrid (paper and electronic) medical records for Resident #168. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, dementia, and muscle weakness. A quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/18/22, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #168 scored a 3 out of 15, which indicated the resident had severe cognitive impairment. A review of the November 2022 Treatment Administration…

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, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to initiate an active care plan for smoking and complete the entire smoking assessment for one (1) of one (1) resident reviewed for smoking (Resident #24). This deficient practice was evidenced by the following: On 8/01/24 at 01:45 PM, the surveyor reviewed the facility provided list of smokers which reflected that Resident #24 was an independent smoker. On 8/05/24 at 10:25 AM, the surveyor reviewed Resident #24's electronic medical record and revealed: Resident #36's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly), acquired absence of kidney (missing one kidney due to an injury or operation), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The most…

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 other pertinent facility documentation it was determined that the facility failed to ensure a resident with history of post-traumatic stress disorder (PTSD) was comprehensively evaluated and care planned to receive appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This deficient practice was identified for one (1) of one (1) resident (Resident #91) reviewed for mood and behavior. This deficient practice was evidenced by the following: On 8/01/24 at 10:01 AM, the surveyor observed Resident #91 resting in bed. The resident was alert, and verbally responsive. Resident #91 stated they liked to stay in their room and watch television. The resident verbalized no concerns. A review of the facility provided matrix (a document used to identify important care categories for residents in the facility) revealed Resident #91 was indicated as having PTSD/Trauma. The surveyor reviewed the electronic medical record of Resident #91 which revealed the following: The admission Record (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, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behavior for the use of a psychotropic medication specifically a antipsychotic medication (used to manage psychosis, a mental disorder characterized by a disconnection from reality) by not having an order for behavior monitoring and indicating the target behavior on the resident's individualized care plan for one (1) of five (5) residents (Resident #36) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 8/06/24 at 9:44 AM, the surveyor observed Resident #36 seated upright in bed. On 8/06/24 at 01:06 PM, the surveyor reviewed Resident #36's hybrid (a combination of paper, scanned, and computer-generated records) medical record. A review of Resident #36's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to acute kidney failure (a condition in which 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 REPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices for one (1) of two (3) staff (Housekeeper) and b.) follow transmission-based precautions (TBP) and enhanced barrier precautions (EBP) protocol to prevent the potential spread of infection for two (2) of two (2) residents (Residents #82 and #108) reviewed for infection control, in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After…

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, it was determined that the facility failed to maintain dignity during mealtime for a resident who needed assistance with eating. This deficient practice was observed for 1 of 25 residents reviewed, Resident #26 and was evidenced by the following: On 8/8/22 at 12:25 PM, the surveyor observed Resident #26 in bed, eating lunch when she called the Certified Nurse's Aide (CNA) for assistance. The CNA entered the resident's room placing paper trash (removed from protected articles on the tray) ex. Straw paper covering) on top of the resident's meal tray. The surveyor further observed that the CNA was standing over the resident while feeding. The surveyor interviewed the CNA on 8/9/22 at 12:30 PM, and specified that staff should be seated next to the resident while assisting them during feeding time. Review of the admission record for Resident #26 documented diagnoses which included but were not limited to Schizophrenia, Chronic Kidney Disease and Arteriosclerotic Heart Disease. The resident's quarterly Minimum Data Set (MDS), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident's call light was readily accessible for a resident who was dependent on staff for care. This deficient practice was identified for 2 of 25 residents reviewed for call bell/light (CBL), Resident #26 and #84, evidenced by the following: 1.) On 8/11/22 at 1:16 PM, the surveyor observed Resident #84's door closed. When the surveyor knocked on the door, the resident stated that she needed the nurse. The surveyor observed that the CBL was hanging toward the floor and out of reach for the resident. The surveyor asked the resident about the CBL. Resident #84 informed the surveyor that they didn't know that there was a CBL to use whenever they needed assistance. The surveyor handed the CBL to the resident. The surveyor observed Resident #84 press the CBL for assistance. A review of the admission record for Resident #84 reflected that the resident was admitted to the facility with diagnoses which…

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

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 1 of 25 residents reviewed for resident assessment (Resident #1). This deficient practice was evidenced by: On 8/17/22 at 1:30 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. Resident #1 was observed to have a Discharge MDS with an Assessment Reference Date (ARD) of 5/13/22 and was due to be transmitted no later than 6/10/22. The MDS was not transmitted until 8/4/22. According to the latest version of the Center for Medicare/Medicaid Services (CMS) - Resident Assessment Instrument (RAI) 3.0 Manual (updated October 2019) page 2-11 Discharge refers to…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure the appropriate management of an enteral feeding formula. This deficient practice was identified for 1 of 5 residents reviewed for tube feeding (Resident #25), and was evidenced by the following: On 8/9/22 at 1:38 PM, the surveyor observed Resident #25 in bed, in a room where the resident was connected to oxygen via tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe) tube along with a feeding pump that was turned off at the time. On 8/15/22 at 11:07 AM, the surveyor observed Resident #25 in bed receiving tube feeding regulated by a pump. The surveyor noted that the feeding pump was set at 60 ml/hr with a total fed display of 1065 ml and 135 ml left to feed. The hanging bottle of Jevity 1.5 Cal had documented information written stating that it was hung on 8/14/22 and started at 4:00 PM at 60 ml/hr. The surveyor noticed that the hanging bottle of Jevity 1.5 Cal which originally contained 1000 ml, was almost completed. On 8/15/22…

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, it was determined that the facility failed to ensure a.) that a concentrator for a resident who was dependent on supplemental oxygen (O2) via a tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe) had the proper settings, b.) that the O2 supply for a resident who was dependent on supplemental O2 via a tracheostomy was connected properly and c.) that a resident who was dependent on supplemental O2 via a tracheostomy had a valid physician's order for O2 in place. This deficient practice was identified for 1 of 2 residents reviewed with a tracheostomy (Resident #25), and was evidenced by the following: On 8/9/22 at 1:38 PM, the surveyor observed Resident #25 in bed in a room where the resident was connected to O2 via a tracheostomy tube along with a feeding pump that was turned off at the time. On 8/15/22 at 11:41 AM, the surveyor entered Resident #25's room and noted the O2 diluter attached to the oxygen and tracheostomy tube was set at 28 which corresponded to 5 liters per minute…

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, review of medical records and other facility documentation, it was determined that the facility failed to a.) accurately follow facility policy related to the wasting of contaminated medication, b.) ensure that physician ordered hold parameters were accurately followed, c.) accurately document the administration of an as needed (prn) controlled substance. This deficient practice was identified for 4 of 24 residents reviewed for medication management (Resident #164, #95, #25 and #161), and was evidenced by the following: 1. On [DATE] at 8:42 AM, the surveyor observed the Unit 1 Registered Nurse (RN) prepare medication for administration to Resident #164. During the medication preparation the RN dropped Losarten 100-12.5 mg (an antihypertensive medication) on the contaminated medication cart. The surveyor observed the RN pick up the Losarten 100-12.5 mg tablet and throw it into the garbage receptacle attached to the medication cart. The surveyor interviewed the RN after she…

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, it was determined that the facility failed to maintain proper infection control practices identified during 3 of 22 residents observed for infection control breaches, Resident # 95, #25 and #61. This deficient practice was evidenced by the following: 1. On 8/11/22 at 9:05 AM, the surveyor observed the Unit 3 Licensed Practical Nurse (LPN3) prepare for the administration of medication to Resident #95. Prior to the administration of medication, LPN3 removed a device from her pocket, a Pulse Oximeter (Pulsox) (a noninvasive device placed on the fingertip which uses a light beam to estimate the oxygen saturation and pulse rate). The surveyor did not observe LPN3 sanitize the Pulsox prior to placing the device on the resident's finger. When LPN3 completed the Pulsox check, she placed the Pulsox back into her pocket. The surveyor interviewed LPN3 in reference to the sanitation of a multi resident use device. LPN3 stated, I cleaned the Pulsox in the morning and put it in my pocket. LPN3 then removed the Pulsox from her pocket and cleaned…

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.