La Grande Post Acute Rehab

Based on interview and record review, it was determined the facility failed to ensure appropriate catheter care and treatment was provided in accordance with professional standards of care for 1 of 3 sampled residents (#3) reviewed for catheters. This placed residents at risk for improper catheter care. Findings include:Resident 3 admitted to the facility in 11/2025 with diagnosis including indwelling urethral catheter.Resident 3's 11/2/25 Physician Order indicated to change foley catheter every 4 weeks using an 18 French catheter one time a day.Resident 3's 11/11/25 progress notes revealed the following:-At 6:36 PM Staff 13 (RN) charted she changed Resident 3's foley catheter.-At 8:30 PM Resident 3 requested Staff 12 (RN) to flush her/his catheter. -At 10:40 PM Staff 12 rechecked Resident 3 and observed no urine drainage over the past two hours. Resident 3 had consumed over 400 cc of water since 8:30 PM. The current foley catheter was a size 20 French. On 2/3/26 at 2:59 PM, Staff 12 stated when she attempted to adjust Resident 3's catheter at his/her request due to discomfort, she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 3 (#1) sampled residents reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Investigation of Alleged Sexual Abuse policy, updated 10/2022, defined sexual abuse as non consensual sexual contact of any type with a resident, which included unwanted intimate touching of any kind, especially the breast or perineal area. Resident 1 was admitted to the facility in 8/2024, with diagnoses including multiple sclerosis. Resident 1's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated she/he was cognitively intact. Resident 2 was admitted to the facility in 5/2024 with diagnoses including stroke. Resident 2's Quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated she/he was cognitively intact. On 2/25/25, the facility submitted a FRI to the State Survey Agency which revealed Resident 2 was…

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 and record review it was determined the facility failed to implement the plan of care for 1 of 3 sampled residents (#2) reviewed for care plans. This placed residents at risk of abuse. Findings include: Resident 2 was admitted to the facility in 5/2024, with diagnoses including stroke. Resident 2's Quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated she/he was cognitively intact. Resident 2's care plan, revised 2/3/25, indicated she/he had disinhibited sexual behaviors related to touching residents of the opposite gender. Interventions included Resident 2 was to be in line of sight of staff and was not to dine with opposite gender residents. On 4/2/25 at 2:12 PM, Resident 1 stated she/he recalled the incident from 3/25/25. She/he revealed Resident 2 had touched her/his genital area over the clothing on that date. Resident 1 stated Resident 2 was taken away from the dining room by a nurse immediately after the incident. On 4/2/25 at 2:17 PM, Staff 5 (CNA) stated she was…

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 maintain hygienic conditions in the facility's walk-in freezer and failed to store food in a hygienic manner in the freezer and dry storage rooms to maintain freshness and prevent the spread of food-borne illness in 1 of 1 kitchen reviewed for food storage. This placed residents at risk of food-borne illness and cross contamination. Findings include: The facility's October 2017 Food Storage policy indicated: -Food storage areas are to be kept clean at all times; -Dry bulk foods are to be stored in seamless plastic or metal bins with tight-fitting lids; and -Items stored in the freezer are to be kept on shelving above the floor. On 2/10/25 at 12:02 PM, during the initial tour of the facility's kitchen, the following was observed in the walk-in freezer: -A discarded frozen snack cup on the floor under the shelving; -A cardboard case of chocolate health shake cartons stored on the floor; -Discarded plastic wrappers scattered on the floor under and between the shelving units; -A plastic-lined…

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 system of accurate reconciliation to account for controlled drugs for 1 of 2 sampled medications carts reviewed for medication storage. This placed residents at risk for misappropriation and misplacement of controlled drugs. Findings include: The facility's 1/2023 Storage of Medication and Controlled Medication Storage Policy & Procedure specified the following: - Medications included in the Drug Enforcement Administration Classifications as controlled substances were subject to special handling, storage, disposal and record keeping. A controlled medication accountability record is prepared when receiving inventory of a schedule 2 medication. At each shift change, a physical inventory of all schedule 2 medication was conducted and was documented on the controlled substances accountability record. Resident 15 was admitted to the facility in 8/2024 with diagnoses including amyotrophic lateral sclerosis (a neurological disorder). Resident 15's 2/2025 Physician Orders did not include…

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.

StaBased on observation, interview and record review it was determined the facility failed to ensure drugs and biologicals were secure for 1 of 1 treatment cart and stored under proper temperatures for 1 of 1 medication refrigerator reviewed for medication storage. This placed residents at risk for misappropriation and reduced medication efficacy. Findings include: The facility's 1/2023 Storage of Medication and Controlled Medication Storage Policy & Procedure specified the following: - Medications and biologicals were stored properly to support safe effective drug administration. - Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F were kept in a refrigerator with a thermometer to allow temperature monitoring. Do not freeze insulin, if insulin has been frozen, do not use. The CDC's 6/18/24 Storage and Handling of Immunobiologics website, https://www.cdc.gov/vaccines/hcp/imz-best-practices/storage-handling-immunobiologics.html#cdc_report_pub_study_section_2-storage-temperature, specified vaccines licensed for refrigerator storage should be…

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

Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 2 of 5 sampled residents (#s 7 and 10) reviewed for medications. This placed residents at risk for being uniformed of psychotropic medication. Findings include: 1. Resident 10 was admitted to the facility in 5/2024 with the diagnoses including anxiety. The 5/25/24 Physician Orders revealed an order for Duloxetine (antianxiety) to be administered daily. Resident 10's medical record revealed no evidence of the risk and benefit information for Duloxetine was reviewed with her/him prior to 10/9/24. On 2/13/25 at 11:52 AM, Staff 3 (RN/Divisional Director of Clinical Operations) confirmed Resident 10 was administered Duloxetine from 5/25/24 to 10/9/24. Staff 3 acknowledged Resident 10 was not provided risk and benefit information related to the use of Duloxetine until 10/9/25. Staff 3 stated she would expect the risk and benefit information provided prior to the administration of Duloxetine. 2. Resident 7 was admitted to the facility…

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 accommodate residents with wheelchair arm rests in safe and proper cleanable order for 1 of 2 sampled residents (#86) reviewed for environment. This placed residents at risk for lack of a clean, safe homelike environment and personal equipment in disrepair. Findings include: On 2/10/25 at 3:28 PM, Resident 86's left wheelchair arm rest was observed with the black surface covering torn and cracked with exposed uncleanable cloth foam. The surface was in disrepair and uncleanable. Record review of the facilities maintenance log dated 12/5/24 to 2/10/25 revealed no reports of Resident 86's or any resident's wheelchair arm rests in poor condition. On 2/11/25 at 12:26 PM Staff 13 (CNA) stated if a resident's wheelchair equipment needed repairs, the staff were to write the concerns in the maintenance log. On 2/11/25 at 1:42 PM, Staff 14 (Maintenance Director) stated staff were to write in the maintenance log when a resident's wheelchair needed repair. Staff 14 confirmed no reports were documented 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.

Based on interview and record review it was determined the facility failed to follow bowel care physician orders for 1 of 5 sampled residents (#10) reviewed for medications. This placed residents at risk for constipation care needs. Findings include: The facility's Bowel Protocol Policy, updated 2018, revealed each resident was placed on a daily bowel monitoring program. The licensed nurse reviewed the bowel monitoring daily. If a resident did not have a bowel movement for three days, the nurse was to administer the physician ordered bowel program or the facility specific PRN medication bowel program. Resident 10 was admitted to the facility in 5/2024 with a diagnoses including pain. Resident 10's 12/1/24 Quarterly MDS indicated she/he was cognitively intact. Resident 10's 1/2025 Physician Orders directed staff to administer the following bowel care medications PRN for constipation: - Senna Oral Tablet; every 24 hours as needed. - Miralax Oral Powder; every 24 hours as needed. - Milk of Magnesia (MOM) Oral Suspension; if resident does not have a bowel movement for three days. -…

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 implement an antibiotic stewardship program for 1 of 1 facilities reviewed for infection control. This placed residents at risk for unnecessary and/or prolonged use of antibiotic medications. Findings include: A review of safety with infection control was performed which included a review of the facilities antibiotic stewardship program. There was no indication of the existence of an antibiotic stewardship program. On 2/13/25 at 12:02 PM, 12:51 PM, and 1:11 PM Staff 3 (Divisional Director of Clinical Operations) stated Staff 2 (DNS) was the current Infection Preventionist, but Staff 2 was out of the facility. Staff 3 stated she was unaware of the existance of an antibiotic stewardship program in the facility. Staff 3 stated four current residents received antibiotics but was unable to verify if the residents were being monitored appropriately for the continued use of an antibiotic. Staff 3 stated Staff 2, Staff 9 (Phamacist), the Executive Director, and the Medical Director should be involved in a monthly…

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 a clean, homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for an environment that was not homelike. Findings include: On 10/2/23 between the hours of 12:10 PM and 2:52 PM the following environmental issues were observed: - room [ROOM NUMBER]'s walls had multiple thick gouges where the paint and sheet rock were missing and the plastic window blinds were broken and bent; - room [ROOM NUMBER]'s floor was sticky with built-up dark debris along the baseboard, the walls were scraped and gouged and the vertical blinds had missing slats; - room [ROOM NUMBER]'s large window had multiple strips of black, white and green tape adhered to various parts of the window. Do not open was hand written on one of the green strips of tape. Glue or adhesive residue was observed from top to bottom of the window and blue painter's tape outlined the entire window; - room [ROOM NUMBER]'s door…

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 consent was obtained prior to administering psychotropic medications to residents for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for being uninformed about their medications. Findings include: The facility's 9/2017 Informed Consent for Psychotropic Drugs Policy specified when the physician ordered an anti-depressant, the facility obtained informed consent from the resident before the drug was administered. Resident 15 was admitted to the facility in 2/2021 with diagnoses including depression. Resident 15's 9/30/23 Physician Order indicated the resident was prescribed trazodone 50 mg for sleep and depression. Resident 15's 9/2023 and 10/2023 MARs revealed the resident received trazodone daily. Review of Resident 15's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of trazodone nor given the opportunity to consent to the medication. On 10/4/23 at 1:46 PM Staff 3 (Social Services Director)…

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 assessed for self-administration of medications for 1 of 7 sampled residents (#10) reviewed for medication administration. This placed residents at risk for unsafe medication administration. Findings include: The facility's 6/2017 Medication Administration Policy specified medications were not to be left at the resident's bedside for the resident to take later. Resident 10 was admitted to the facility in 3/2020 with diagnoses including heart failure. Resident 10's 9/6/23 Quarterly MDS indicated the resident was cognitively impaired. On 10/5/23 at 8:19 AM Staff 4 (CMA) was observed for medication administration. Staff 4 dispensed the following medications into a plastic cup: - Colace 100mg (stool softener) - furosemide 20mg (diuretic) - losartan 25mg (blood pressure) - gabapentin 100mg (pain) - Jardiance 10mg (diabetes) - Urecholine 10mg (urinary retention) - Eliquis 2.5mg (blood clot prevention) - metformin 500mg (diabetes) - fiber powder, 1 scoop added to a cup of water…

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 complete a comprehensive assessment in activites for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for unidentified care needs. Findings include: Resident 19 was admitted to the facility in 9/2021 with diagnoses including aphasia (language disorder which affects one's ability to communicate) and dementia. Resident 19's 5/25/23 Annual MDS assessed her/him was unable to answer cognition questions, with memory problems and no recall of information. Section F, Activities Preferences, indicated she/he enjoyed the use of a phone in private, participating in her/his favorite activities and spending time outdoors. The assessment indicated her/his family or representative was not interviewed to obtain answers for the resident. Resident 19's 5/25/23 MDS CAAs for Activities revealed the resident has some cognitive issues that make it difficult for [her/him] to express [her/his] needs. [She/he] seems to have some understanding at times. [She/he] usually just smiles when spoken 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 interview and record review it was determined the facility failed to ensure resident care plans were revised to accurately reflect resident needs for 1 of 5 sampled residents (#11) reviewed for unnecessary medications. This placed residents at risk for unmet needs. Findings include: Resident 11 was admitted to the facility in 4/2023 with diagnoses including congestive heart failure. Resident 11's 7/18/23 Significant Change in Status MDS revealed the resident required extensive assistance from at least one staff in the areas of bed mobility, transfers, dressing, toilet use and personal hygiene. Resident 11's 8/16/23 ADL Self-Care Performance Deficit Care Plan revealed the following: - The resident required supervision with bed mobility. - The resident was able to transfer with supervision. - The resident was able to dress her/himself with supervision. - The resident required limited assistance from one staff person with toilet use. - The resident was able to independently perform personal hygiene tasks after set-up. On 10/5/23 at 9:42 AM Staff 9 (CNA) stated she found…

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 provide an ongoing program to support individual activity interests and preferences for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for unmet psychosocial needs. Findings include: The facility's 7/2015 Activity Program Policy and Procedure indicated the facility provided an ongoing program of activities designed to meet the interests as well as physical, mental and psychosocial well-being of each resident. Activities included individual, small and large group, one-to-one, and independent activities to meet resident's needs, abilities and interests. For residents who remained in their room, the Activity Department provides and assists with in-room activities/projects/leisure pursuits in keeping with needs, abilities, and interests. Resident 19 was admitted to the facility in 9/2021 with diagnoses including aphasia (language disorder which affects ability to communicate), depression, insomnia (sleeplessness) and dementia. Resident 19's 5/25/23 Annual MDS…

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

Based on observation, interview and record review the facility failed to ensure the environment was free of potential accident hazards for 1 of 3 residents (#22) reviewed for accidents. This placed the residents at risk for potential accidents. Findings include: Resident 22 admitted to the facility in 8/2023 with diagnoses including abnormalities of gait (manner of walking) and mobility, weakness and dementia. Residents 22's 10/2023 Physician Order, initiated on 8/10/23, directed staff to place the resident's bed against the wall on one side. Resident 22's 10/3/23 In-Room Care Plan directed staff to place the resident's bed against the wall on one side and a fall mat on the opposite side. Review of the 10/3/23 IDT (Inter Disciplinary Team) Review form revealed Resident 22 experienced a fall on 9/28/23 in her/his bedroom. The9/28/23 fall assessment indicated the contributing factor of the fall was the resident's lack of safety awareness. Observations on 10/3/23 at 10:16 AM and 10/4/23 at 9:48 AM and 12:56 PM Resident 22 was observed to sit on her/his bed while the bed was positioned…

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 identify, assess and monitor weight loss for 1 of 4 sampled residents (#11) reviewed for nutrition. This placed residents at risk for unidentified weight changes. Findings include: The facility's 12/2016 Procedure for Managing Weight Loss and Weight Gain indicated the following: - Report abnormal results to the Wellness Director or Community Director, Dietician, physician, and the resident's family if the resident is not their own person: a. A 5 percent or more decrease/increase in weight since the last recorded weight or within the past 30 days. b. A 7.5 percent or more decrease/increase in weight since the last recorded weight or within the past 90 days. c. A 10 percent or more decrease/increase in weight since the last recorded weight or within the past 180 days. - Report changes or differences in health status, service needs, or preferences to the Community Director, Wellness Director, Dietician, and/or designated staff. - Once the attending physician has been notified that their resident…

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 respiratory equipment was properly maintained and used as ordered for 1 of 2 sampled residents (#11) reviewed for respiratory care. This placed residents at risk for discomfort. Findings include: The facility's 1/2015 Maintenance Program-Oxygen Concentrators Policy included the following related to equipment maintenance: - Oxygen tubing, cannula (medical device used to provide supplemental oxygen therapy) and humidifier bottle to be cleaned daily. - Cabinet air filter to be cleaned weekly. Resident 11 was admitted to the facility in 4/2023 with diagnoses including congestive heart failure. Resident 11's 8/16/23 Congestive Heart Failure Care Plan revealed the following: - Oxygen via nasal prongs at two liters as needed to maintain saturation of oxygen over 90 percent and humidified. Resident 11's 8/23/23 Physician Orders included a PRN order for two liters of oxygen per minute via nasal cannula to keep O2 sats greater than 90 percent for hypoxemia. On 10/2/23 at 2:07 PM and 10/3/23 at…

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

Based on observation, interview and record review it was determined the facility failed to ensure safe and secure storage of medicated powder for 1 of 2 sampled residents (#15) reviewed for skin conditions. This placed residents at risk for receiving incorrect medication and treatment. Findings include: Resident 15 was admitted to the facility in 2/2021 with diagnoses including depression. Resident 15's 9/1/23 Significant Change in Status Assessment revealed the resident was severely cognitively impaired. Resident 15's 5/2023 Physician Order included nystatin powder (a medication used to treat fungal infections) bid to the groin area. On 10/2/23 at 11:30 AM two unlabeled, plastic medication cups filled with white powder were observed on Resident 15's nightstand. Resident 15 stated staff applied the powder from those cups to her/his groin area every day for her/his rash. On 10/5/23 at 12:39 PM Staff 12 (LPN) stated medicated powders were stored in a locked treatment cart. Staff 12 stated medicated powders, such as nystatin, should be applied by the nurse and not left in a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, interview and record review it was determined the facility failed to ensure appropriate infection control practices during medication administration for 4 of 5 sampled residents (#s 10, 17, 23 and 131) observed for medication administration. This placed residents at risk for spread of infection. Findings include: The facility's 3/2018 Handwashing/Hand Hygiene Policy specified hand hygiene was the primary means to prevent the spread of infection and should be performed before and after preparing medications. Resident 10 was admitted to the facility in 3/2020 with diagnoses including heart failure. Resident 17 was admitted to the facility in 8/2021 with diagnoses including stroke. Resident 23 was admitted to the facility in 5/2023 with diagnoses including lung disease. Resident 131 was admitted to the facility in 9/2023 with diagnoses including heart failure. On 10/4/23 at 11:14 AM Staff 4 (CMA) dispensed and administered Resident 131's medications. At 11:17 AM Staff 4 returned to the…

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

Based on observation, interview and record review the facility failed to ensure reisdent rooms were designed and equipped for adequate privacy for 1 of 1 sampled resident (#19) reviewed for activities. This placed residents at risk for lack of priviacy and dignity. Findings include: Resident 19 was admitted to the facility in 9/2021 with diagnoses including aphasia (language disorder which affects ability to communicate) and dementia. On 10/2/23 at 2:52 PM Resident 19's window blinds were observed with three vertical slats missing and the common area to the soda machines was visible from her/his bed. On 10/3/23 at 11:49 AM the facility's written repair maintenance binder was reviewed and no repair for the missing blinds were reported. On 10/3/23 at 9:38 AM Staff 11 (CNA) stated when Resident 19 received personal care in her/his bed, the blinds covered the window for privacy. On 10/3/23 at 1:50 PM Staff 15 (Administer in Training/Temporary Maintenance) stated the condition of resident rooms and the building in general was audited weekly. At 2:06 PM Staff 15 walked through 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.