El Jen Skilled Care

Based on interview, record review and document review, the facility failed to ensure an alleged incident of verbal abuse was reported to the State Agency (SA) within the required timeframes for 1 of 12 sampled residents (Resident #11). The deficient practice had the potential to place residents at risk for incidents of verbal abuse to not be adequately protected. Findings include: Resident #11 (R11) was admitted to the facility 03/09/2023 with a diagnosis including parkinsonism, dysphagia, cognitive communication deficit, and depression. A Behavior Note dated 10/10/2024, documented R11 was standing in the hallway with a butter knife in their sleeve threatening to harm another resident. A Facility Reported Incident (FRI) was submitted to the SA on 10/15/2024, documenting the resident's alleged verbal abuse on 10/10/2024. On 12/18/2024 at 3:46 PM, the Administrator/Abuse Coordinator verbalized abuse without serious bodily harm should be reported to the SA within 24 hours of the incident. The Abuse Coordinator confirmed the FRI was not reported to the SA within the required timeframes.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician's orders for the application of heel protectors were followed for 1 of 12 sampled residents (Resident 5). The deficient practice had the potential to lead to the development of skin breakdown. Findings include: Resident 5 (R5) was admitted on [DATE], with diagnoses including [NAME] syndrome and peripheral vascular disease. Physician's orders dated 09/02/2023 documented: -Bilateral heel protectors on at all times when in bed every shift for pressure relief and skin prophylaxis. The wound care progress note dated 11/12/2024, documented R5 was treated for a chronic non-healing arterial ulceration of the left anterior fifth toe. This was a 30 day follow up for a previously healed wound. Wound remains healed. Please continue using preventive measures which can include turning and repositioning, offloading, and nutritional supplementation. On 12/18/2024 at 11:15 AM, R5 was noted to be lying on their back, on an air mattress in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and document review the facility failed to ensure abuse policies and procedures were implemented for 1 of 5 sampled residents. The deficient practice had the potential to put residents at risk of negative physical or psychosocial outcomes. Findings include: Resident 3 (R3) R3 was admitted on [DATE] and readmitted on [DATE] with diagnoses including anxiety, mood disorder, and unspecified psychosis. A facility report indicated a Certified Nursing Assistant (CNA1) was walking past room of R3 where another Certified Nursing Assistant (CNA2) was providing care to the resident. CNA1 reported hearing a noise which sounded like a hand slapping against skin or body part. The facility investigation documented CNA1 walked past room and had concern CNA2 was being physically abusive to R3, however did not intervene to stop the alleged abuse. CNA1 walked past the resident's room and directly to the charge nurse to report suspected abuse. The witness statements from CNA1 confirmed CNA1 did…

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, interviews, record reviews, and document reviews, the facility failed to ensure an incident in which an elderly resident with dementia and Alzheimer's disease was forced to take medications was promptly reported to the abuse coordinator and the agency within the mandated timeframes for 1 of 5 sampled residents (Resident 5). This deficient practice had the potential to lead to unaddressed abuse and compromise the resident's health and well-being. Findings include: Resident 5 (R5) R5 was admitted on [DATE], with diagnoses including Alzheimer's disease and dementia. The Minimum Data Set, dated [DATE], documented a brief interview of mental status score of 99, which indicated the interview had not been completed due to impairment of R5's cognitive status. A Care Plan dated 09/22/2022, documented R5 had episodes of resistance to care during the medication pass. The interventions included re-approaching R5 calmly, redirecting behavior, and re-offering medication. The facility report dated…

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 document review, the facility failed to follow its abuse protocol, specifically, staff members who witnessed, or were aware of a resident-to-resident altercation did not report the allegation of physical abuse to the Abuse Coordinator or designee for 2 of 2 sampled residents (Residents 1 and 2). The deficient practice placed the residents of concern and other residents at risk for abuse and maltreatment. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including schizoaffective disorder bipolar type and encephalopathy. Resident 2 (R2) R2 was admitted on [DATE], with diagnoses including Alzheimer's disease of late onset and age-related physical debility. A behavior note dated 11/22/2023, revealed R2 attempted to wrap a blanket around roommate's neck trying to choke R1 and then tried to put a heel-floater boot on R1's face trying to choke R1. Staff intervened and separated the residents. A new order for room changes by psychiatry provider also…

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 document review, the facility failed to ensure the views and recommendations of the resident group were acted upon, and the response and rationale communicated back to the resident group. The failed practice had the potential to affect the quality of life and health status of some residents. Findings: The policy and procedure titled Resident Council, Revised February 2021, indicated the purpose of the resident council was to provide a forum for residents to have input on the operation of the facility, including discussions of concerns and suggestions for improvement. The policy indicated the Resident Council Response Form was utilized to track issues and their resolutions. The facility department which was related to any specific issues was responsible for addressing the item(s) of concern. Resident council meeting minutes documented the following: On 02/22/2023, 16 residents and five staff had attended a resident council meeting. New Business notes indicated issues of Breakfast, chicken and pork terrible tasting. Want to discuss menu changes 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 document review, the facility failed to safely secure hazardous items and medications. The deficient practice had the potential to increase concerns about resident safety within the facility and potential harm. Findings include: On 08/30/2023 at 12:10 PM, outside of resident room W04 was an unattended maintenance tool cart with items to include chemicals (professional sprayer in a spray bottle), screws, a hammer, wrenches, screw drivers, caulking material, and a 4.5 gallon of joint compound. On 08/30/2023 at 12:12 PM, a Certified Nursing Assistant (CNA) verified the maintenance tool cart was unattended and indicated the unattended maintenance tool cart was not safe and posed a hazard for residents. Shortly after, a Plant and Maintenance staff member exited resident room W04. The Plant and Maintenance staff member indicated the maintenance tool cart should not be left unattended as someone could have gotten items from the cart. On 08/30/2023 at 12:40 PM, a second Plant and Maintenance staff member verbalized a maintenance tool cart should not 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 observation, interview and document review, the facility failed to 1) knock on resident room doors for 2 of 28 sampled residents (Resident 55 and 109), 2) ensure staff were not standing during feeding assistance for 1 unsampled resident (Resident 69) and 3) appropriately transport a resident from the shower room for 1 of 28 sampled residents (Resident 2). The deficient practices had the potential to compromise dignity, impact the residents' sense of well-being and feelings of self-worth and self-esteem. Findings include: Resident 55 (R55) R55 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. Resident 109 (R109) R109 was admitted on [DATE] with diagnoses including abdominal aortic aneurysm, unspecified sequelae of cerebral infraction, and polyneuropathy. On 08/30/2023 at 9:32 AM a Certified Nursing Assistant (CNA1) entered room N03 without knocking or announcing self. On 08/30/2023 at 10:09 AM, a Registered Nurse (RN)…

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 document review, the facility failed to ensure a resident was assessed for self-administration of medication for 1 of 28 sampled residents (Resident 114). The deficient practice had the potential to lead to medication errors impacting the well-being of the resident. Findings include: Resident 114 (R114) R114 was admitted on [DATE] with diagnoses including age-related physical debility, acquired absence of other specified parts of digestive tract and perforation of intestine. The Brief Interview of Mental Status dated 08/29/2023, documented a score of 14/15, which meant R114's cognitive status was intact. On 08/29/2023 at 11:31 AM, a medication cup filled with an orange liquid was observed on R114's bed side tray table. R114 indicated the orange liquid was medication to assist in gaining weight, a nurse left the medication with R114 to self-administer prior to eating lunch, and R114 was waiting to receive their lunch tray. R114 specified only one nurse who…

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 document review, the facility failed to ensure residents were notified through postings in prominent locations throughout the facility, of the right to file a grievance with, and contact information for the pertinent state agency. The deficient practice had the potential to result in a resident having an unresolved grievance. The facility policy and procedure titled Grievance/Complaint Reporting, dated 06/01/2023, indicated the facility would provide the name, address and telephone number of state advocacy groups and information on how to file a grievance. On 08/30/23 at 2:31 PM, five out of five residents in a group interview stated they did not know they could file a grievance with the state agency. On 08/31/23 at 1:29 PM a facility tour with the Administrator revealed the facility lacked any posting visible to residents bearing the name and contact information for the pertinent state agency. The Administrator verbalized such information should be posted prominently in various areas of the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and document review, the facility failed to ensure a physician order was obtained or transcribed, and consent for the resident's transitioning to a secured unit was granted for 1 of 28 sampled residents (Resident 104). This deficient practice could potentially have led to resident's frustration, isolation, depression, emotional distress, a reduced quality of life, and a decline in their overall well-being. Findings include: Resident 104 (R104) R104 was admitted on [DATE], with diagnoses including epilepsy, lack of coordination and unsteadiness on feet, and major depressive disorder. The Brief Interview of Mental Status dated 07/10/2023, documented a score of 15/15, which indicated R104's cognitive status was intact. The Nursing Evaluation dated 05/01/2021, documented R104 was not at risk for elopement or wandering. R104's Minimum Data Set (MDS) revealed functional status with transfer, walk in room locomotion on and off unit, eating, and personal hygiene required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was initiated for a resident who was admitted with an indwelling catheter for 1 of 28 sampled residents (Resident 132). The deficient practice placed the resident at risk for receiving inappropriate catheter care. Findings include: R132 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis with cerebral infarction and urinary retention. On 08/29/2023 at 11:39 AM, R132 laid awake in a low bed. The resident was uncovered which revealed an incontinent brief, an indwelling catheter tubing stabilized on left upper thigh and a covered urinary bag hanging on left side of the bed. A Nursing admission/readmission evaluation dated 07/17/2023, revealed R132 was admitted with an indwelling catheter 20 French (Fr -diameter size) and 30 cubic centimeters (cc) bulb for urinary retention. A physician's order dated 07/17/2023, documented indwelling Foley catheter 20 Fr 30 cc balloon 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 document review, the facility failed to ensure a compression stocking was applied to treat edema as ordered for 1 of 28 sampled residents (Resident 104). This deficient practice placed the resident at risk of exacerbation of the resident's condition and could have compromised their overall health management. Findings include: Resident 104 (R104) R104 was admitted on [DATE], with diagnoses including pain and hypertension. The Brief Interview of Mental Status dated 07/10/2023, documented a score of 15/15, which indicated R104's cognitive status was intact. The admission Nursing assessment dated [DATE], documented R104 had edema of bilateral lower extremities (BLE). The Physician Progress Notes (undated), documented the assessment and plan, indicating BLE chronic edema elevation at bedtime and compression stockings were available. A Physician order dated 03/23/2023, documented the placement of compression hose stockings on BLE in the morning and off at bedtime for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure appropriate indwelling catheter care was provided and physician's orders were followed for 2 of 28 sampled residents (Resident 132 and 116). The deficient practice potentially resulted in a urinary tract infection (UTI) for Resident 132 and placed Resident 116 at risk for urethral trauma. Findings include: Resident 132 (R132) R132 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis with cerebral infarction and urinary retention. On 08/29/2023 at 11:39 AM, R132 laid awake in a low bed. The resident was wearing an incontinent brief, an indwelling catheter tubing was stabilized on left upper thigh and a covered urinary bag hung on left side of the bed. A Nursing admission/readmission evaluation dated 07/17/2023, revealed R132 was admitted with an indwelling catheter 20 French (Fr diameter size) and 30 cubic centimeters (cc) bulb for urinary retention. A physician's order dated 07/17/2023,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure a resident's midline intravenous dressing change was performed in accordance with facility policy and physician's orders for 1 of 28 sampled residents (Resident 130). The deficient practice placed the resident at risk for phlebitis (site infection). Findings include: Resident 130 (R130) R130 was admitted on [DATE], with diagnoses including end-stage renal disease and osteomyelitis of the foot. On 08/29/2023 at 10:37 AM, R130 was seated on the left side of the bed, an intravenous (IV) access with purple port was observed on R130's left upper arm. The IV access was covered in transparent dressing with a soiled gauze pad underneath. The IV dressing was dated 08/28/2023 and was coming loose on all ends, a strip of plastic tape reinforced the right side of the dressing. R130 pointed to an IV pole on the left side of the bed and indicated receiving IV antibiotics for a foot infection. According to R130, the IV dressing…

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 document review, the facility failed to ensure the Oxygen (O2) order was followed for 1 of 28 sampled residents (Resident 91). This deficient practice could lead to serious health complications, incorrect dosages, or adverse reactions. Findings include: Resident 91 (R91) R91 was admitted on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) with exacerbation, dependence on supplemental Oxygen and obstructive sleep apnea. The Brief Interview of Mental Status dated 07/12/2023, documented a score of 15/15, which indicated R91's cognitive status was intact. The Minimum Data Sheet dated 07/12/2023, documented R91 was on Oxygen therapy. A Care Plan dated 04/28/2023, documented R91 had altered respiratory status due to COPD and smoking. The interventions included administering the medication and treatment as ordered. A physician order dated 07/18/2023, documented the administration of O2 inhalation at 2 liters per…

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 document review, the facility failed to ensure a pain medication was not administered late for 1 of 28 sampled residents (Resident 101). This deficient practice placed the resident at risk for inadequate pain relief, potential discomfort and compromised quality of life. Resident 101 (R101) R101 was admitted on [DATE] with diagnoses including muscle spasm and fibromyalgia. The Brief Interview of Mental Status dated 06/13/2023, documented a score of 15/15, which meant R101's cognitive status was intact. On 08/29/2023 at 8:58 AM, R101 indicated they endured pain due to having fibromyalgia and their scheduled muscle relaxer medication was sometimes administered late which made them feel frustrated. R101's medical record revealed a physician had an order on dated 03/13/2023 for Tizanidine HCL tablet, four milligrams (mg); give one tablet by mouth three times a day related to other muscle spasm. The August 2023 Medication Administration Record (MAR) revealed…

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 document review, the facility failed to ensure 1) dialysis communication records were completed for 1 of 28 sampled residents (Resident 130) and 2) an agreement was obtained with the dialysis provider for 1 of 28 sampled residents (Resident 130) and one unsampled resident (Resident 343). The deficient practice potentially placed the residents at risk for improper coordination of care between the facility and the dialysis provider. Findings include: Resident 130 (R130) R130 was admitted on [DATE], with diagnoses including end-stage renal disease (ESRD), diabetes mellitus and osteomyelitis of the foot. On 08/29/2023 at 10:37 AM, R130 pulled down shirt which revealed a right central venous catheter (CVC) dressed in white gauze. R130 explained the CVC was used for dialysis (renal replacement therapy). A physician's order dated 07/17/2023, revealed R130 was scheduled to receive dialysis at a dialysis clinic on Tuesdays, Thursdays, and Saturdays with a prescribed run…

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 document review, the facility failed to ensure a sufficient supply of a prescribed medication for 1 of 28 sampled residents (Resident 124). The deficient practice resulted in an omitted dose and placed the resident at risk for hypertension. Findings include: Resident 124 (R124) R124 was admitted on [DATE], with diagnoses including essential hypertension. On 08/30/2023 at 9:10 AM, a Licensed Practical Nurse (LPN) was observed preparing and administering R124's routine morning medications. A physician's order dated 08/18/2023, documented to give Amlodipine Besylate 10 milligrams (mg) one tablet by mouth once daily for hypertension. Hold for systolic blood pressure (BP) less than 110 millimeters of Mercury (mmHg). On 08/30/2023 at 9:13 AM, the LPN indicated R124's anti-hypertensive medication Amlodipine was scheduled to be administered and the resident met the criteria with a recorded BP of 120/99 mmHg. The LPN held the empty medication blister pack of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review the facility failed to ensure it was free from a medication error rate of five percent (%) or greater for three unsampled residents (Residents 32, 3 and 124). The deficient practice placed residents at risk for medication errors. Findings include: On 08/30/2023 in the morning, a Medication Administration Pass observation was performed with 28 opportunities observed and revealed three errors. The medication error rate was 10.71 %. Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including heart failure and epilepsy. On 08/30/2023 at 8:43 AM, a Licensed Practical Nurse (LPN) prepared and administered the following medications to R32: - Ferrous Sulfate 325 milligrams (mg) one tablet - Folic acid 400 micrograms (mcg) one tablet - Gabapentin 100 mg one tablet - Apixaban 5 mg one tablet - Levetiracetam 500 mg one tablet - Divalproex 250 mg extended release three tablets - Cephalexin 500 mg one tablet - Metoprolol succinate 250 mg extended…

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 document review, the facility failed to ensure food was palatable, attractive, and served at an appetizing temperature when hot cereal was prepared and served with a solid consistency rather than the customary semi-liquid consistency; and not served at an appetizing temperature (too cold), for one sampled resident (Resident 89) and two unsampled residents. The deficient practice had the potential to decrease the amount of nutrients consumed by residents, and also the resident's perception of their quality of life. Findings: On 08/31/2023 at 8:10 AM, Resident 89 (R89) was alert and answered questions appropriately. R89 verbalized having been served cream of wheat in the form of one large cold lump in the bowl. R89 reported having to ask staff for assistance in breaking up the lump so it could be consumed. On 08/29/2023, in the morning, one unsampled resident complained of being served hard (congealed) cream of wheat with today's breakfast. On 8/31/2023 at 8:00 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure expired medications were removed from the active medications and discarded for 4 of 4 medication rooms. Findings include: On 06/16/2022 at 10:10 AM, an inspection was conducted in four medication rooms accompanied by the nurse supervisor. The medication refrigerator in each medication room was locked and temperatures were monitored. Expired medications were found inside the refrigerator together with the active medications in the following units: 1) Rehab Medication Room -Aplisol injection, expiry date 05/23/2022 -Hemorrhroidal Prep, expiry date 08/2021 -Acephen suppositories 650 mg, 12 suppositories, expiry date 08/2021 -Influenza vaccine, expiry date 09/2019 -Prochlorperazine 25 milligram suppositories, expiry date 01/13/2021 2) Retirement Medication Room -Magnesium Citrate Laxative, date opened 09/12/2021, expiry date 03/2022 -Pneumonia vaccine, 2 vials, expiry date 05/2021 -Insulin Lispro Injection 1 vial (10…

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 document review, the facility failed to ensure 1) expired items were discarded, 2) opened food items were labeled and dated, 3) cleanliness of the kitchen, 4) Ice build-up in the freezers, 5) kitchen logs were completed, 6) dishwasher was at correct temperature, 7) food items were covered during meal delivery, and 8) food temperatures were taken prior to meal service. Findings include: On 06/14/2022 at 8:21 AM, during the initial kitchen tour of the kitchen revealed the following: 1) Expired items: Dry Storage: -Cream of Wheat packets with expired date of 09/22/2021 -Stevia sugar packets with expired date of 04/26/2021 2) Opened items unlabeled and undated included: Reach-in refrigerator next to juice station: -Three containers of soup base Storage Shelf above toaster: -Container of seasoned salt 3) Cleanliness: -Freezer 1, Freezer 2, and Freezer 3 had food particles and food pieces on the bottom of shelf -Shelf under the steam table had dried up food debris 4) Ice build-up in the freezers -Freezer 2 pipe near the top shelf was covered in ice…

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 document review, the facility failed to ensure a resident's dignity and privacy by not covering a urinary catheter drainage bag for 1 of 33 sampled residents (Resident 116). Findings include: Resident 116 (R116) was admitted on [DATE], with diagnoses including kidney failure and morbid obesity. On 06/14/2022 at 10:35 AM, R116 was in bed, asleep. R116's urinary bag was hanging at the bedside, uncovered and visible from the door entrance of R116's room. The urinary catheter bag was transparent with 300 milliliters of amber-colored urine. On 06/14/2022 in the afternoon, R116 was lying in bed alert and verbally oriented. R116 indicated bed confinement and dependence on activities of daily living. R116 was admitted three weeks ago with a Foley catheter. R116 was not aware the urinary bag was uncovered and visible by the entrance door. R116 indicated embarrassment regarding uncovered urine bag that others might see. A Care Plan dated 06/14/2022, documented 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 document review the facility failed to 1) report a resident's COVID positive status, 2) room change and 3) change in condition to the family for 1 of 33 sampled residents (Resident 275). Findings include: Resident 275 (R275) was admitted on [DATE], with diagnoses including cerebral atrophy and psychosis. 1) R275's medical record documented a positive COVID - 19 test result dated 01/20/2022. The progress notes had no notes from nursing and physicians as to why the resident was tested for COVID. 2) R275's medical record documented a room change from S10 to 307 on 01/22/2022. The progress notes had no notes from nursing as to why the resident was transferred to another room. 3) R275's progress notes dated 01/27/2022, revealed the Nurse Practitioner (NP) documented nurses had reported a decrease in R275's food & fluid intake. The NP ordered the resident to be started on intravenous fluids (IVF) until diet improved. Blood work in the morning, nutrition supplement and dietitian…

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

Based on interview, record review and document review, the facility failed to ensure employees contracted through an internet-based app that links healthcare workers with available shifts in healthcare facilities were screened for criminal background and job references and received abuse and neglect training prior being allowed to work alone with residents for 5 of 12 reviewed personnel files (Employee 8, 9, 10, 11 and 12). Findings include: On 06/17/2022 in the afternoon, employee's files were reviewed. Employee 8 (E8) E8's personnel records revealed the employee was contracted to perform duties as a Certified Nursing Assistant (CNA) through an internet-based app that linked healthcare workers with available shifts in healthcare facilities. The record documented the employee worked at the facility on 02/09/2022, 02/10/2022, 02/11/2022, 02/12/2022, 02/14/2022, 02/15/2022, 02/17/2022, 02/19/2022, 02/20/2022, 02/21/2022, 02/22/2022, 02/23/2022, 04/04/2022, and 04/05/2022. E8's personnel record lacked documented a completed background check was performed and previous employment…

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 document review, the facility failed to develop a person-centered comprehensive care plan for a nutritional concern for 2 of 33 sampled residents (Resident 59 and Resident 106). Findings include: Resident 59 (R59) was admitted on [DATE] and readmitted on [DATE], with diagnoses including injury of nerve root of cervical spine, contracture of right elbow, stage 4 pressure ulcer of right buttock, unstageable pressure ulcer of left heel, and chronic pain. A Nutritional Comprehensive assessment dated [DATE], documented R59 had a stage 4 pressure ulcer to the right buttock. The nutritional diagnoses revealed R59's increased nutrient needs related to metabolic demand for increased nutrients as evidenced by stage 4 sacral pressure ulcer. R59's nutritional intervention was to start Arginaid one packet twice a day for wound healing. A Nutritional Care Plan revised 05/18/2022, documented R59 had a nutritional problem or potential nutritional problem related to diet restrictions for 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 observation, interview, record review, and document review, the facility failed to ensure a shower or bed bath was provided as scheduled for 2 of 33 sampled residents (Resident 422 and Resident 428). Findings include: 1) Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease. On 06/14/2022 at 11:37 AM, R422 was in bed watching television. R422's hair was unkempt, messy, and had an unshaven face. R422 indicated nobody had offered or helped the resident shave and had not showered since arriving at the facility over a week ago. R422 indicated they would like their beard shaved, showered, and to feel clean when going out the dialysis clinic. The Nursing Admission/readmission Evaluation dated 06/07/2022, documented R422 required total dependence for bath or shower. The 5-Day Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15/15 which meant the cognitive status was intact. R422 required extensive…

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 document review, the facility failed to ensure the intravenous (IV) antibiotic medication to treat a leg infection was administered as ordered for 1 of 33 sampled residents (Resident 116). Findings include: R116 (R116) was admitted on [DATE], with diagnoses including kidney failure, diabetes mellitus, and leg infection. On 06/14/2022 at 10:25 AM, R116 was in bed asleep. Ceftriaxone was given through an IV in the right upper arm. On 06/15/2022 at 1:55 PM, R116 indicated the Ceftriaxone should be administered daily but was inconsistently given. R116 expressed requests were made, but the staff did not regularly give the IV antibiotic for unexplained reasons. R116 had spoken to the nursing supervisor and the issue was reported. The Brief Interview of Mental Status dated 06/04/2022, documented the score of 15/15, which indicated R116's cognitive status was intact. A physician order dated 06/10/2022, documented Ceftriaxone Sodium Solution 2 gram (gm) IV 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure heel protection devices were applied to prevent pressure ulcer for 1 of 33 sampled residents (Resident 172). Findings included: Resident 172 (R172) was admitted on [DATE], with diagnoses including down syndrome, morbid obesity. A Braden Scale dated 03/15/2022, documented the resident had moderate risk for pressure ulcer development. A Nursing Progress Note dated 03/24/2022, documented on assessment R172 was found having an unstageable pressure ulcer to right lateral ankle. The progress note indicated the attending physician was called and ordered wound consult with the wound care physician and wound care team, and the treatment for the pressure ulcer including to cleanse the injury with normal saline solution, pat dry, apply Iodosorb ointment, cover with dry dressing, change every Tue, Thu, Sat and as needed for soiled and dislodgement until 04/21/2022. A Wound Care Physician assessment dated [DATE], revealed 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 document review, the facility failed to provide restorative services for 1 of 33 sampled residents (Resident 93). Findings include: Resident 93 (R93) was admitted on [DATE], and readmitted on [DATE], with diagnoses including monoplegia of lower limb following cerebral infarction, and chronic obstructive pulmonary disease. On 06/15/2022 at 8:31 AM, R93 indicated their left leg was paralyzed and was not receiving therapy or restorative services to get stronger. R93 indicated it had been a few weeks since receiving restorative services and did not receive therapy or restorative services since returning to the facility. R93 would like to get stronger working with therapy or restorative services. The 5-Day Minimum Data Set (MDS) dated [DATE], documented R93's Brief Interview for Mental Status (BIMS) score of 15/15 which meant the cognitive status was intact. The Nursing Admission/readmission Evaluation dated 05/13/2022, documented R93 had permanent physical impairment due 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 document review, the facility failed to ensure a power cord was safely plugged-in to prevent a tripping hazard for 1 of 33 sampled residents (Resident 10). Findings include: Resident 10 (R10) was admitted on [DATE], with diagnoses including psychosis, lack of coordination, absence of left leg below the knee, and history of falling. On 06/14/2022 at 1:30 PM, the Oxygen (O2) concentrator was running and plugged into a power cord, and the power cord was plugged into an electrical outlet across R10's room. On 06/15/22 in the morning, R10 and staff members were observed going in and out of the room. A power cord was plugged across R10's room. R10 was able to transfer independently from bed to a wheelchair. On 06/15/2022 at 2:30 PM, R10 was in bed. A Certified Nursing Assistant (CNA) confirmed the power cord was plugged right across R10's room entrance. The CNA indicated the power cord was a tripping hazard. On 06/15/2022 at 2:35 PM, the nurse supervisor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure a resident was appropriately assessed for the use of a Foley catheter, a physician order was obtained, and urine output was monitored for 1 of 33 sampled residents (Resident 116). Findings include: Resident 116 (R116) was admitted on [DATE], with diagnoses including kidney failure, morbid obesity, anemia, and diabetes mellitus. On 06/14/2022 at 10:35 AM, R116's urine drainage bag was hanging next to the bed, uncovered, and could be seen from the doorway of the room. 06/14/22 in the afternoon, R116 was in bed. The Foley bag was beside the bed, draining 250 ml of amber-colored urine. R116 was in bed, alert and verbally oriented. R116 indicated bed confinement and dependence on activities of daily living. R116 was admitted three weeks ago with a Foley catheter. R116 indicated the Foley was inserted in the hospital but was previously able to control bladder function. The admission Evaluation dated 05/25/2022, lacked…

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 document review, the facility failed to 1) provide nutritional assessments for 2 of 33 sampled residents (Residents 106 and 422), and 2) Registered Dietitian (RD) recommendations were communicated to the physician and processed for 2 of 33 sampled residents (Residents 59 and Resident 106). Findings include: 1) Nutritional Assessments Resident 106 (R106) was admitted on [DATE], with diagnoses including dysphagia, dementia, and signs and symptoms concerning food and fluid intake. The Quarterly Minimum Data Set (MDS) dated [DATE], documented R106 had significant weight loss of 5% or more in the last month or loss of 10% or more in the last six months. R106 was not on a physician-prescribed weight-loss regimen. The medical record lacked documented evidence a quarterly nutritional assessment and progress note was done to address R106's weight loss. On 06/15/2022 at 3:05 PM, the RD indicated nutritional assessments were completed within seven days after admission, quarterly, 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, record review, and document review, the facility failed to ensure an intravenous (IV) midline dressing was changed within 24 hours upon insertion and weekly thereafter per policy for 2 of 33 sampled residents (Residents 116 and 422). Findings include: A facility policy titled Midline Dressing Changes, revised 11/2016, indicated the midline catheter dressings would be changed at specific intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Change midline catheter dressings every 24 hours after catheter insertion, every 5 days, or if they are wet, dirty, not intact, or compromised in any way. Resident 116 (R116) was admitted on [DATE], with diagnoses including kidney failure, cellulitis (deep infection of the skin), diabetes mellitus, and leg infection. The Brief Interview of Mental Status dated 06/04/2022, documented the score of 15/15, which indicated R116's cognitive status was intact. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to monitor the resident's pain level for 1 of 33 sampled residents (Resident 422). Findings include: Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease. On 06/14/2022 at 11:37 AM, R422 indicated the pain medication provided would last three to four hours then the pain in their hands and feet would increase to a pain level of 9 out of 10. R422 indicated the nurses were not monitoring their pain and they would have to wait till the next pain pill was brought to them. R422 indicated they had notified the nurse of the pain returning after a few hours, but they explain the next pain pill was not due yet. On 06/15/2022 at 2:00 PM, R422 indicated the pain in their hands and feet were currently at level 9 out of 10 and needed pain medication. R422 indicated the nurse provided pain medication in the morning but did not ask if they were in any pain. R422 indicated the nurse…

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 document review, the facility 1) failed to complete necessary dialysis communication records and 2) ensure dialysis related medication was administered per physician orders for 1 of 33 sampled residents (Resident 53). Findings include: Resident 53 (R53) was admitted on [DATE] with diagnoses including type II diabetes and end stage renal disease requiring dialysis. 1) A physician order dated 04/27/2022, documented dialysis three times per week (Monday, Wednesday, and Friday), pick up at 9:00 AM. The medical record from May of 2022 to current, lacked dialysis communication on the following dates: 05/04/2022, 05/09/2022, 05/11/2022, 05/13/2022, 06/08/2022, 06/10/2022, and 06/15/2022. On 06/16/22 at 4:00 PM, the nurse caring for R53 indicated the dialysis communication record should be sent to the dialysis center with the resident and received from the dialysis center every time the resident goes for dialysis treatment. The nurse indicated if the resident returns…

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 document review, the facility failed to ensure medications were available during medication pass to ensure timely administration per policy for 2 of 33 sampled residents (Residents 116 and 43). Findings include: 1) Resident 116 (R116) was admitted on [DATE], with diagnoses including diabetes mellitus with foot ulcer and cellulitis of the right lower limb. On 06/16/2022 at 9:30 AM, a medication pass observation was conducted in the Retirement Unit. Licensed Practical Nurse 2 (LPN2) prepared and administered R116 morning medications, except IV Lactobacillus capsule. LPN2 explained the Lactobacillus was not available. LPN2 explained the Lactobacillus order was different from the one available in the medication cart and would be ordered by central supply. A physician order dated 05/31/2022, documented to give Lactobacillus capsule by mouth three times a day for gastrointestinal prophylaxis. On 06/16/2022 at 11:30 AM, the Director of Central Supply indicated 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, record review, and document review, the facility failed to ensure their medication error rate was not five percent or greater when four errors were identified with 29 opportunities observed calculating an error rate of 13.79%. Findings include: A facility policy titled Adverse Consequences and Medication Errors, revised 04/2014, revealed listed medication errors like not giving a drug that was ordered, giving the wrong drug, or giving it at the wrong time. A facility policy titled Medication Administration Schedule, Revised 11/2020, documented the scheduled medications were administered within one hour of their prescribed time. The exact time of medication administration is documented in the MAR. If medication is administered early, late, or is omitted, the reason is also documented. 1) Resident 2 (R2) was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation and acute chronic respiratory failure with hypoxia. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and document review, the facility failed to ensure a residents food allergy was honored and not served for 1 of 33 sampled residents (Resident 422). Findings include: Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease. On 06/14/2022 at 3:36 PM, R422 indicated the staff were providing peanut butter and chicken which the resident was allergic to. R422 indicated anaphylactic shock would occur if they consumed chicken and peanut/peanut butter which had occurred a few years ago. R422 indicated they would check the food to ensure it was something they could have so they would not have to be hospitalized for eating foods they were allergic to. R422 indicated the nurses would provide a peanut butter and jelly sandwich as a snack during the night and they would need to send it back for a sandwich without peanut butter. The Diet Order slip dated 06/07/2022, documented R422 was a new admission on a cardiac/renal…

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.