Curry Village Health And Rehab Of Cascadia

Based on observation, interview, and record review it was determined the facility failed to ensure residents did not receive unnecessary psychotropic medications and failed to monitor for side effects of psychotropic medications for 2 of 5 sampled residents (#s 7 and 28) reviewed for medications. This placed residents at risk for adverse side effects of medications. Finding include: 1. Resident 7 was admitted to the facility in 10/2017 with diagnoses including anxiety disorder. A review of Resident 7's signed physician orders dated 1/15/25 instructed staff to administer Xanax (to treat anxiety) every eight hours PRN for anxiety for 90 days, starting on 10/18/24. A review of the 1/2025 MAR instructed staff to administer Xanax every eight hours PRN for anxiety for 90 days, starting on 10/18/24. The MAR indicated Resident 7 was administered Xanax on 1/17/25, 1/18/25, 1/19/25 1/22/25, 1/23/25, 1/26/25, 1/27/25 and 1/28/25. Resident 7 was administered Xanax eight times after the end date of 1/16/25. No end date was documented on the MAR. On 1/30/25 at 6:28 AM, Staff 8 (LPN) stated staff…

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 the facility failed to ensure a medication error rate of less than 5%. The facility administration error rate was 7.41% with two errors in 27 opportunities. This placed residents at risk for an ineffective medication regimen. Findings include: Resident 92 was admitted to the facility in 1/2025 with a diagnosis of malnutrition. A 1/27/25 hospital After Visit Summary form revealed Resident 92 was to be administered medications including Ferrous Sulfate EC (enteric coated) 324 mg (supplement) and Calcium with Vitamin D (supplement). On 1/28/25 at 7:48 AM Staff 11(LPN) was observed to administer Resident 92 medications including one Slow Iron 45 mg tablet. Staff 11 did not administer Calcium with Vitamin D. On 1/28/25 at 9:24 AM Staff 11 stated when a resident was admitted to the facility with new orders Staff 18 (Medical Records) entered the orders into a resident's clinical record and a nurse was to review the orders prior to administering the medications to ensure all the orders were entered correctly. Staff 11…

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 the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) and 2 of 4 halls (#s 1 and 3) reviewed for dignity and random observations. This placed residents at risk for lack of dignity. Findings include: 1. Resident 2 was admitted to the facility in 12/2010 with diagnosis including quadriplegia. A 7/24/23 Quarterly MDS revealed Resident 2 had an indwelling catheter. On 9/18/23 at 2:37 PM Resident 2 stated she/he preferred to have her/his urinary catheter bag covered with a privacy bag when she/he was in bed. The urinary catheter bag was observed hanging on the bed with no privacy cover and urine could be seen in the bag. Resident 2 stated people should not have to look at her/his urine. On 9/20/23 at 7:18 AM Resident 2 was in bed with urinary catheter bag hanging on the bed with no privacy bag. Urine could be observed in the bag from the hallway outside of Resident 2's room. On 9/20/23 at 10:48 AM Staff 4 (CNA) stated Resident 2's urinary catheter bag should have…

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.

5. Resident 1 was admitted to the facility in 6/2002 with diagnosis including cerebral palsy (a movement disorder). An 8/3/23 Multidisciplinary Care Conference form revealed the following: -Meeting time and date were blank. -Attendance was blank. -Key review section was blank. -Resident and responsible party expectations and concerns were blank. -Comments and recommendations had notes with names of two other people who were not the resident and information about the two other people. -Recommendation section was blank. -The check boxes for care plan reviewed and updated and current orders and care plans reviewed with resident or representative and copies provided were not marked. A review of Social Services Notes for 7/2023 and 8/2023 revealed no social service notes pertaining to care conferences. On 9/21/23 at 12:52 PM Staff 3 (Social Services Coordinator) stated Resident 1's care conference date was noted as 8/3/23 on her hand-written calendar. Staff 3 stated she would have to look for additional information about the care conference. No additional information was provided. 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.

Based on interview and record review it was determined the facility failed to ensure a RN was available for at least eight consecutive hours per day seven days per week for 9 out of 32 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: Direct Care Daily Staff Reports reviewed from 8/19/23 through 9/19/23 indicated there was no RN coverage on the following dates: 8/25/23, 8/26/23, 8/30/23, 9/1/23, 9/7/23, 9/8/23, 9/9/23, 9/15/23, and 9/16/23. On 9/21/23 at 10:45 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated one of the facility's RNs retired and there were now some days without the required RN staffing.

Based on interview and record review it was determined the facility failed to ensure an antibiotic stewardship program was implemented for 1 of 1 facility and for 1 of 1 sampled resident (#3) reviewed for UTI. This placed residents at risk for worsening infections. Findings include: An Antibiotic Stewardship Policy last revised on 10/15/22 revealed the IP would track cultures and sensitivity reports routinely as part of the surveillance of the infection. Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. Resident 3's 9/15/23 and 9/16/23 Progress Notes revealed the resident had increased confusion, the physician was notified and a urine sample was obtained to rule out a UTI. The resident was started on Levofloxacin (antibiotic) per physician orders. The 9/15/23 final urine culture was received at the facility via fax on 9/20/23. This was five days after the culture was verified. The culture results revealed the resident was on the appropriate antibiotic to eliminate Resident 3's infection. On 9/20/23 at 2:07 PM with Staff 2 (DNS) and Staff 14 (LPN…

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 ensure residents received vaccines, education, and risk and benefits for 5 of 5 sampled residents (#s 2, 7, 11, 15, and 16) reviewed for immunizations. This placed residents at risk for infections and lack of information. Findings include: 1. Resident 2 was admitted to the facility in 2010 with diagnoses including paralysis. Resident 2's record revealed the resident received a pneumonia vaccine but the consent with risk and benefits was not located in the resident's record. The record also did not indicate which pneumonia vaccine the resident received. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated Resident 2 received the PPSV23 vaccine, acknowledged Resident 2's pneumonia series was not complete and the record did not include the consent with risk and benefits. 2. Resident 7 was admitted to the facility in 2018 with diagnoses including heart failure. Resident 7's record revealed the resident received the PPSV23 vaccine but the consent with risk and benefits was not in the resident's…

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

Based on observation, interview, and record review it was determined the facility failed to ensure preferences were honored for 1 of 2 sampled residents (#2) reviewed for choices. This placed residents at risk for lack of support for preferences. Findings include: 1. Resident 2 was admitted to the facility in 12/2010 with diagnosis including quadriplegia. The 7/24/23 Quarterly MDS revealed Resident 2's BIMS score was 15 which indicated the resident was cognitively intact. a. A revised 8/7/23 care plan indicated Resident 2 had a self-care performance deficit and needed assistance with her ADLs. Resident 2 preferred to be up in her/his wheelchair for breakfast and required two staff assist for morning care. Resident 2 prefered early morning showers. On 9/19/23 at 8:46 AM Resident 2 was observed in bed eating her/his breakfast. On 9/20/23 at 7:18 AM Staff 5 (CNA) was in Resident 2's room while Resident 2 was in her/his bed. Staff 5 stated to Resident 2 as soon as she got all the feeders (residents who require assistance with eating) up she would come back and assist Resident 2 to get…

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

Based on interview and record review it was determined the facility failed to ensure a resident was provided advance directive information for 1 of 2 sampled residents (#3) reviewed for advance directives. This placed residents at risk for end-of-life decisions not being honored. Findings include: Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. An 8/10/23 Clinical Evaluation admission form revealed the resident did not have an advance directive. An 8/15/23 admission MDS indicated Resident 15 was cognitively intact. An 8/31/23 Care Plan revealed staff were to review advance directive information with Resident 3 and/or her/his appointed representative on admission, with a change of condition and at least quarterly. There was no documentation on the care plan to indicate advance directive information was provided. On 9/20/23 at 12:26 PM Staff 3 (Social Services Coordinator) stated if a resident had an advance directive it was scanned into the record. If the resident did not have one, the information was offered and then documented in the…

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

Based on observation, interview, and record review it was determined the facility failed to ensure resident privacy was provided for 1 of 3 sampled residents (#2) reviewed for dignity. This placed residents at risk for lack of privacy. Findings include: Resident 2 was admitted to the facility in 12/2010 with diagnosis including quadriplegia. The 7/24/23 Quarterly MDS revealed Resident 2 had a BIMS score of 15 which indicated the resident was cognitively intact with no behavioral concerns. An 8/27/23 revised care plan revealed Resident 2 had an ADL self-care performance deficit with interventions including the resident required one staff for bathing, and two staff for AM shift care. On 9/18/23 at 2:49 PM Resident 2 stated she/he felt exposed as staff only partially closed her/his privacy curtain and not her/his room door during cares. Resident 2 indicated when she/he could see people in the hallway, the people in the hallway could see her/him. On 9/20/23 at 10:48 AM Staff 4 (CNA) stated when only one staff member assisted Resident 2, staff left the room door ajar because Resident 2…

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-up on a resident grievance in a timely manner for 1 of 1 sampled resident (#8) reviewed for personal property. This placed residents at risk for missing personal items. Findings include: Resident 8 was admitted to the facility in 2020 with diagnoses included muscle weakness. A 7/17/23 admission MDS revealed the resident was cognitively intact. An 8/2/23 Concerns/Complaints/Compliments/Grievances Follow-up form revealed the resident reported she/he was missing four shorts, three sweat pants, three shirts, one underwear and two jeans. The form indicated the CNAs, housekeeping and social services searched the facility for the missing clothing. There was no resolution documented on the form. On 9/18/23 at 3:45 PM Resident 8 stated she/he received clothing for her/his birthdays and holidays and many items were missing including jeans. She/he submitted a grievance and did not have a resolution yet. Resident 8 stated all her/his clothing were marked with her/his name. On 9/20/23 at 12:07 PM Staff 3 (Social…

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 ensure a resident was permitted timely return to the facility after a scheduled outpatient medical procedure for 1 of 1 sampled resident (#83) reviewed for change of condition. This placed residents at risk for loss of rights to return to the facility. Findings include. Resident 83 was admitted to the facility in 2023 with an arm fracture. Resident 83's 4/12/23 and 4/13/23 Progress Notes revealed the ward clerk made arrangements for the resident to go the the hospital emergency department to have her/his cast removed because the resident refused to attend the scheduled orthopedic office appointment to have the cast removed. The resident's physician was notified and the resident was agreeable to go to the hospital via non-emergent transport to be evaluated for x-rays and cast removal. There was no indication in Resident 83's record she/he was discharged from the facility. An 4/14/23 Emergency Department Note revealed the resident was sent to the emergency department because the resident refused to be seen…

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 ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalization for 1 of 1 sampled resident (#15) reviewed for hospitalization. This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: Resident 15 was admitted to the facility in 7/2023 with diagnosis of kidney disease. The 7/11/23 Health Status Note indicated Resident 15 was sent to the hospital. The 7/18/23 admission Summary Note indicated Resident 15 readmitted to the facility. No evidence was found in the resident's clinical record to indicate the Office of the State Long Term Care Ombudsman was notified of Resident 15's hospitalization. On 9/21/23 at 11:15 AM Staff 1 (Chief Executive Officer) stated historically the facility did not send out written hospital notifications for the Office of the State Long Term Care Ombudsman.

Based on interview and record review it was determined the facility failed to ensure a significant change MDS was completed for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 5 was admitted to the facility in 2023 with diagnoses related to adult failure to thrive. Resident 5's Progress Notes dated 8/14/23 and 8/16/23 revealed the resident's physician discontinued all non-essential medications, she/he was discharged from skilled therapy and placed on comfort care. On 9/20/23 at 10:53 AM Staff 15 (RNCM) stated on 8/14/23 Resident 5 elected end of life care provided by the facility versus hospice services. Staff 15 stated a significant change MDS should have been completed but was not done.

2. Resident 19 was admitted to the facility in 2023 with diagnoses including pneumonia. Resident 19's current care plan identified problems of diabetes, use of an intravenous line for the delivery of antibiotics, dehydration related to poor intake and pain related to skin conditions. The care plan did not include: -The use of two diuretics (medication to increase urination) to treat lymphedema (blockage in the lymph system causing swelling in the arms or legs) which could lead to dehydration. -Lymphedema, diabetic neuropathy (nerve damage leading to pain and numbness), peripheral vascular disease (plaque build up restricting blood flow causing pain and leg cramps) and immobility which could cause pain. -Visual problems due to glaucoma and a cataract. -Severe kidney disease with recent consideration for dialysis (a process to eliminate toxins from the blood). -Sleep apnea (condition that causes a person to stop breathing while sleeping). On 9/22/23 at 8:55 AM Resident 19's care plan was discussed with Staff 2 (DNS). Staff 2 stated she expected resident conditions being treated at the…

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

Based on interview and record review it was determined the facility failed to ensure a resident was provided supplies for independent in-room activities for 1 of 2 sampled residents (#8) reviewed for activities. This placed residents at risk for lack of meaningful activities. Findings include: Resident 8 was readmitted to the facility in 2023 with diagnoses including heart disease. A 7/17/23 admission MDS revealed Resident 8 was cognitively intact and it was somewhat important for her/him to do her/his favorite activities. Resident 8's 8/23/23 through 9/20/23 activity documentation revealed Resident 8 participated in two group activities. There was no one to one activity or self directed activity documented. A Care Plan initiated 5/26/23 revealed staff were to invite the resident to activities of choice, provide an activity calendar and respect the resident's wishes to decline activities. The care plan did not specify the type of activities the resident liked or the type of supplies the resident may need. On 9/18/23 at 3:38 PM Resident 8 stated the facility had supplies in a bin,…

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 physician orders for 2 of 5 sampled residents (#s 1 and 8) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 1 was admitted to the facility in 6/2002 with diagnoses including diabetes. A signed 9/1/23 physician order instructed staff to check Resident 1's BMP (basic metabolic panel, a group of blood tests to show how well the kidneys work), CPK (creatine phosphokinase, a blood test that measures the creatine in the blood, an enzyme required for muscle function and energy production) and ALT (alanine transaminase, a blood test which measures the amount of ALT in the blood to help with early detection of liver disease) every three months in March, June, September and December with an order date of 4/17/19. No documentation was found in clinical record to indicate Resident 1's 6/2023 BMP, CPK and ALT tests were completed. On 9/22/23 at 8:14 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated it was expected of staff to…

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

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient fluids were provided for 1 of 1 sampled resident (#3) reviewed for hydration. This placed residents at risk for dehydration. Findings include: Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. A Care Plan initiated 8/15/23 indicated the resident was at risk for dehydration due to the use of diuretics (medications to help remove extra fluids from the body) and staff were to monitor the resident. An 8/25/23 Nutrition Evaluation Comprehensive form revealed the resident's most recent laboratory studies and meal intakes were reviewed. The resident's fluid consumption was assessed to average 120 to 240 ml per meal. The resident was assessed to require 1650 to 1850 mL each day. The recommendation was for the resident to be on a hydration pass. Resident 3's Care Plan was not updated to include a hydration pass after the 8/25/23 nutrition evaluation. Resident 3's record did not include additional documentation to indicate the resident received…

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 up on pharmacy recommendations for 3 of 5 sampled residents (#s 1, 8, and 19) reviewed for medications. This placed residents at risk for ineffective and adverse medication reactions. Findings include: 1. Resident 1 was admitted to the facility in 6/2002 with diagnoses including schizoaffective disorder (a mental health disorder with symptoms such as delusions and hallucinations), and depression. a. An 8/4/23 Behavior Psychoactive Meeting revealed pharmacy and physician recommendations. Resident 1 was due for a gradual dose reduction of risperidone (used to treat certain mental and mood disorders), fluoxetine (used to treat depression), and divalproex sprinkles (used to treat epilepsy and bipolar disorder). A letter was sent to the physician. A 9/6/23 Consultation Report indicated a repeat recommendation from 8/9/23: Resident 1 received risperidone, fluoxetine, and divalproex sprinkles and was due for an annual review of the medications. The report had a fax date on the top of 9/19/23 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 interview and record review it was determined the facility failed to ensure residents were provided non-pharmacological interventions prior to the use of PRN psychotropic medications for 2 of 5 sampled residents (#s 5 and 8) reviewed for medications. This placed residents at risk for sedation. Findings include: 1. Resident 5 was admitted to the facility in 2023 with diagnoses including failure to thrive. Resident 5's Progress Notes dated 8/14/23 and 8/16/23 revealed the resident's physician discontinued all non-essential medications, the resident was discharged from skilled therapy and placed on comfort care. A 9/2023 MAR from 9/1/23 through 9/19/23 revealed the resident was administered lorazepam (antianxiety medication) up to four times a day for anxiety/restlessness. The documentation indicated the medication was effective. The MAR also had directions for staff to try non-pharmacological interventions prior to use of PRN medications including repositioning, offer warm blankets, distraction and to decrease environment stimulation, and staff were to document 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 record review it was determined the facility failed to ensure 2 of 2 staff (#s 12 and 13) wore appropriate PPE for a resident who required aerosol generating proceduress (AGPs). This placed residents at risk for cross contamination. Findings include: On 9/20/23 at 9:15 AM room [ROOM NUMBER] was observed with a sign on the door. The sign included the resident had AGPs completed at 7:47 AM, precautions ended at [no time was written]. The sign instructed authorized, trained staff to wear a gown, N95 mask, eye protection and gloves. Staff 12 (Housekeeper) was observed to enter the room with only a surgical mask and gloves. Staff 12 stated she only wore eye protection and a gown if a resident had COVID-19. On 9/20/23 at 9:30 AM Staff 13 (Activities Assistant) was observed to enter room [ROOM NUMBER] with only a surgical mask. On 9/20/23 at 9:32 AM and 10:15 AM Staff 14 (LPN IP) stated all staff were to wear PPE as directed on the sign for two hours after the AGPs stopped.

Based on interview and record review it was determined the facility failed to ensure residents received risk and benefits of the COVID-19 vaccine for 3 of 5 sampled residents (#s 7, 15, and 16) reviewed for immunizations. This placed residents at risk for uninformed decisions. Findings include: 1. Resident 7 was admitted to the facility in 2018 with diagnoses including heart failure. Resident 7's record revealed the resident received the COVID-19 vaccines and boosters in 2021 and 2022. The record did not include education was provided to the resident including the risks and benefits. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she was not able to find documentation to indicate staff provided education to Resident 7 prior to the vaccines. 2. Resident 15 was admitted to the facility in 2022 with diagnoses including kidney disease. Resident 15's record revealed she/he refused the COVID-19 vaccines and boosters, dates were not listed. The record did not include education was provided to the resident including the risks and benefits. On 9/20/23 at 4:00 PM 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.