Cranford Park Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the presence of a stage III pressure ulcer for one of three residents (Resident (R) 71) reviewed for pressure ulcers out of a sample of 18. This failure created potential for an incomplete or ineffective plan of care related to pressure ulcer treatment and healing measures. Findings include: Review of R71's Diagnosis tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had diagnoses including dementia, aphasia, depression, anxiety, and chronic pain. Review of R71's quarterly MDS with an Assessment Reference Date (ARD) of 07/31/25, located under the MDS tab of the EMR, revealed she did not have any current pressure ulcers. Review of R71's Care Plan, dated 05/23/25 and located under the Care Plan tab of the EMR, revealed, The resident has a stage 3 pressure ulcer on the sacrum r/t [related] to impaired mobility, incontinent. 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 one of three residents (Resident (R) 71) reviewed for pressure ulcers out of a sample of 18 received physician-ordered pressure ulcer prevention measures. This failure created potential for development of avoidable pressure ulcers and associated risks for pain, infection, and slow healing.Findings include: Review of R71's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had diagnoses including dementia, aphasia, depression, anxiety, and chronic pain. Review of R71's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/25, located under the MDS tab of the EMR, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and had short- and long-term memory problems and severely impaired cognition. R71 was dependent on staff for all activities of daily living and bed mobility. R71 was at risk for pressure ulcer…

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 #NJ00179350, NJ00182926 Based on interviews, medical record review, and review of other pertinent facility documents on 6/3/25, 6/5/25, and 6/19/25 it was determined that the facility failed to consistently document in the Documentation Survey Report on care provided to dependent residents according to facility policy and protocol for 3 of 3 residents (Resident #1, Resident #5, and Resident #6) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: Dementia, Muscle weakness, Diabetes Mellitus Type 2 The surveyor reviewed Resident #1's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/10/25, which indicated that Resident #1 had a BIMS of 9 out of 15, indicating moderate cognitive impairment. The MDS further indicated that the resident required assistance with Activities of Daily Living (ADLs). A review of Resident # 1's Documentation Survey Report v2 (DSR) dated May 2025,…

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 00182926 Based on interviews, medical records reviews, and review of other pertinent facility documentation, on 06/03/25, 06/05/25, and 06/19/25, it was determined that the facility failed to revise a care plan after an annual assessment for a cognitively impaired resident that needed assistance with meals. The facility also failed to follow its Care Plan policy. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for care plans and was evidenced by the following: Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus and Encounter for Palliative Care. A review of the resident's annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/18/2025, revealed that Resident #6 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated…

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 submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for the PBJ Report submission for Fiscal Year (FY) Quarter 1 2024 (October 1-December 31) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area indicating the facility failed to submit data for the first Fiscal Year Quarter to CMS. The dates of the first quarter included October 1, 2023, through December 31, 2023. On 3/19/24 at 10:00 AM, the Licensed Home Administrator (LNHA) informed the survey team that the facility used a third party to submit the PBJ Staffing Data Report to CMS. The third party did not provide a CMS validation or any proof of submission to CMS for staffing reported for the FY Quarter 1 2024. On 3/27/24 at 11:15 AM, the surveyor interviewed the LNHA, in the presence of another surveyor, regarding communication of staffing with CMS and he stated, We…

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 record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 7 of 19 residents (Resident #41, 9, 53, 3, 50, 66, and #10) and reviewed for resident assessment. According to the Long-Term Care RAI 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool and a federally mandated process for clinical assessment of all residents. It 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. This deficient practice was evidenced by the following: On 3/19/24, at 9:30 AM, the surveyor reviewed the facility task that includes residents' MDS assessments, which was triggered…

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 the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 5 of 19 residents reviewed (Resident # 69, # 9, # 57, #63, and # 24). The deficient practice was evidenced by the following: 1. The surveyor reviewed Resident # 69's records. The resident was discharged from the facility and according to the Discharge Return Anticipated MDS, an assessment tool used to facilitate the management of care, dated 2/23/24, the resident was assessed as being discharged to the hospital. A review of Resident # 69's progress notes dated 2/23/24 revealed the resident had actually been discharged home, against medical advice. On 3/25/24 at 11:49 AM, the surveyor interviewed the MDS Coordinator (MDSC), who stated that the MDS under section A, which is she completes, for Resident #69 should have indicated discharge to home and that it was an error that it indicated discharge to 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 review of other pertinent facility documentation, it was determined that the facility failed to implement an intervention timely that was recommended by the wound physician. This deficient practice was identified for one of one resident (Resident #28) reviewed. This deficient practice was evidenced by the following: On 3/18/24 at 11:02 AM, the surveyor observed the Resident #28 lying in bed on an air mattress. The resident responded to questions in a faint voice. The resident gave permission to speak with the spouse who was in the room. The spouse stated, [The resident] came here because of a stroke about six months ago. On 3/18/24 at 11:26 AM, the surveyor interviewed the daughter who stated, [the resident] was in the hospital in New York for gastrointestinal bleed and has renal cancer that metastasized to the brain. The resident also had another brain bleed and had radiation therapy recently in the hospital. [the resident] has a sacral wound, stage four, from the hospital from a year ago. On 3/20/24 at 11:25 AM, observed 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, interview, and review of other pertinent facility documents, it was determined that the facility failed to ensure a.) implementation of interventions designed by the occupational therapist to stimulate functional performance, and prevent further decline, and b.) the interdisciplinary team provided timely revision to the care plan (CP). This deficient practice was identified for one (1) of one (1) resident reviewed for limited range of motion, Resident #29 and was evidenced by the following: 1. On 3/25/24 at 10:33 AM, the surveyor observed the resident with one foot out of the blanket, the chest, and both hands were covered with a blanket. On 3/26/24 at 9:24 AM, the surveyor and the Certified Nursing Assistant (CNA) assigned to the resident, entered the resident's room. The resting hand splint (RHS; a medical device, functional hand brace, wrist, and finger immobilizer) was observed next to the resident's bedside table. The CNA stated that she had fed the resident, who at that time threw 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 review of other pertinent facility provided documentation, the facility failed to a) follow through with the Dietitian's recommendation for one (1) of two (2) residents (Resident #24), b) ensure the Interdisciplinary team (IDT) was aware of the resident's significant weight loss according to the standard of clinical practice for one (1) of two (2) residents (Resident #24), and c) ensure that the re-weigh was done according to the standard of clinical practice and facility policy for two (2) of two (2) residents, Resident #24 and #57, reviewed for nutrition. 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 and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) maintain the necessary care and maintenance of a respiratory equipment and b.) provide a physician's order for respiratory care in accordance with professional standards of practice for one of one resident, (Resident #58) reviewed for respiratory care. This deficient practice was evidenced by the following: On 3/18/24 at 10:35 AM, the surveyor observed the Resident #58 lying in a low bed to the ground. A nebulizer mask was on the bedside table in a bag and the label on the tubing was dated 3/11/24. The resident was pleasant, alert, and oriented to person, place and time. The resident stated, I am here because I have pneumonia (an infection of the lungs) and I need to get my breathing better again. On 3/20/24 at 11:03 AM, the surveyor observed the resident in the therapy gym using the bike with no evidence of difficulty breathing while biking. On 3/20/24 at 11:07…

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 provide pharmaceutical services in accordance with professional standards by ensuring that an expired controlled drug (Lorazepam gel) was removed from active inventory after 1/22/24 and had accurate corresponding documentation for the removal and administration for Resident #39 in one (1) of three (3) medication carts observed during the medication storage inspection. 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 and 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 regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45,…

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 the facility failed to follow professional standards and practices to accurately document in the medical record an ordered medication a resident was being administered. The concern was cited for 2 (Residents #57 and #377) of 19 residents reviewed and is evidenced by the following. 483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are (ii) accurately documented. 1. On 3/19/24 at 12:51 PM, the surveyor reviewed the medication orders for resident #377 in the electronic medical record (EMR). The medication orders reflected that resident #377 had a physician's order for and was being administered Lantus insulin (Lantus) (a long-acting injectable medication used to treat diabetes). On 03/20/24 at 9:51 AM, the surveyor reviewed the EMR for resident #377. The review included documentation recorded by the attending physician and associated nurse practitioners reflected as Plan of Care (POC) notes, Physician Progress Notes and Chronic 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, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for Resident #24. This deficient practice was identified for one (1) of 19 residents reviewed, and was evidenced by the following: According to the MDS (minimum data set) 3.0 RAI (Resident Assessment Instrument) Manual included that the SCSA is a comprehensive assessment for a resident must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary…

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 the medical record and review of other facility documentation, it was determined that the facility failed to maintain professional standards of clinical practice by failing to assess the fall risk for a resident that was at risk for falls and had a fall according to the facility policy for 1 of 2 residents reviewed for falls (Resident #63). This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. 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 well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board.…

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, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a pneumococcal vaccine for 1 of 6 residents reviewed for immunizations (Resident #63). The deficient practice was evidenced by the following: The surveyor reviewed Resident #63's medical record. A review of Resident #63 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 anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), muscle weakness (decreased strength in the muscles) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident #63's quarterly Minimum Data Set (MDS), an assessment tool used 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 3 of 3 nursing units, (A-unit, B-unit, and C-unit) reviewed for environmental concerns and for 1 of 1 resident, (Resident #63) reviewed for tube feedings. This deficient practice was evidenced by the following: 1. On 09/06/23 at 12:11 PM, the surveyor toured the C-unit, entered room C5 and observed that the white molding on the bottom of the wall which was in contact with the floor was stained with yellow and black discolorations. In addition, the top of the molding behind the bed's headboard that was positoned on the same wall as the door entryway was chipped off, exposing discolored brownish-black wood. The surveyor further observed green privacy curtains throughout room. Two of the privacy curtains were observed with brown and red stains…

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 pertinent facility documentation, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 of 20 resident's, (Resident #8) reviewed for accurately coding the MDS. The deficient practice was evidenced by the following: On 09/06/23 at 12:06 PM, the surveyor observed Resident #8 seated in his/her reclining chair in the main dining/activity room on the C unit. The resident was observed bopping their head to music that was playing in the background. The surveyor reviewed the medical record for Resident #8. Review of the resident's admission Record indicated that the resident had resided at the facility for several years and had diagnoses which included but were not limited to bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and hypertension. Review of the resident's September 2023…

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 pertinent facility documentation, it was determined that the facility failed to clarify a Physician's Order (PO) for the dosage of a medication on the electronic Medication Administration Record (eMAR) for several months. This deficient practice was identified during the medication pass observation for 1 of 6 residents, (Resident #16) reviewed and 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 physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board.…

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

Based on observation, interviews and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 09/05/23 at 10:25 AM, the surveyor toured the kitchen in the presence of the Food Services Director (FSD) and observed the following: 1. On a metal rack in the refrigerator, there was an opened box labeled bacon with the inner plastic bag open and the bacon visible and exposed to air. The FSD acknowledged that the bacon should not have been exposed to air and stated that it was important to make sure the bacon was covered properly to avoid sickness. 2. On the bottom shelf on a metal rack in the freezer, there were four (4) five-pound freezer sealed bags of dark reddish chunks of meat with no label and no dates. The FSD identified the meat as cubed beef 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 review of pertinent facility documentation, it was determined that the facility failed to: a.) appropriately label, date and store biologicals and b.) discard medications after the manufacturer specified use by date. This deficient practice was identified during 2 of 2 medication storage room (B-unit medication storage room and C-unit medication storage room) inspections and was evidenced by the following: 1. On [DATE] at 11:54 AM, the surveyor inspected the medication storage room on the B Unit. The surveyor observed one unlabeled clear orange pill bottle which contained an unidentified clear liquid. The surveyor interviewed the Licensed Practical Nurse (LPN) at the time of inspection who stated that she could not identify what type of liquid was being stored in the clear orange pill bottle on the counter of the medication storage room. On [DATE] at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical…

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

Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 3 units, (B unit). The deficient practice was evidenced as follows: On 09/07/23, the surveyor observed the following during lunch meal pass on the B-unit: At 12:36 PM, in the pantry room, a Recreation Aide (RA) removed the ice scoop from the wall holder and scooped ice from a cooler, poured the ice into a cup, replaced the ice scoop to the holder, placed the cup on a meal tray and placed the tray on Resident #16's bedside table in his/her room. The RA returned to the pantry and retrieved a meal tray and placed it on Resident #46's side table in his/her room. In the same room, the RA then pulled the privacy curtain around Resident #57, turned, and rested her left hand on Resident #46's pillow that was behind his/her head while the resident was seated in a recliner chair. The RA pulled the recliner chair to reposition the resident in the room, moved…

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.