Avamere Transitional Care At Sunnyside

Based on observation, interview, and record review it was determined the facility failed to ensure residents' rights to a dignified existence for 2 of 5 sampled residents (#s 3 and 15) reviewed for dignity and respect. This placed residents at risk for diminished quality of life. Findings include: 1. Resident 3 was admitted to the facility in 2020 with diagnoses including morbid obesity and depression. A care plan dated 2/1/20, revealed Resident 3 was independent with transferring herself/himself in the room, utilized a bed side commode, and required one-person assistance with toileting hygiene. A Grievance Communication Form Dated 9/30/24, revealed the following: - Resident 3 turned on the call light for help at 12:15 PM. At 12:30 PM, Resident 3 placed herself/himself on the beside commode. At 1:15 PM, her/his roommate went out and asked staff for help. At 1:20 PM, almost one hour after the resident turned on the call light, a CNA entered the room and helped Resident 3 off the bedside commode. -Staff 41 (Former CNA) stated Resident 3 indicated her/his call light was on for 45…

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

Based on interview and record review it was determined the facility failed to notify the physician regarding a change in condition for 1 of 4 sampled residents (#5) reviewed for change of condition. This placed residents at risk for lack of physician involvement. Findings include: The facility's Change in a Resident's Condition or Status Policy Statement dated 2/2021 directed the nurse to notify the resident's attending physician or the on-call physician of a significant change in the resident's physical condition. Resident 5 was admitted to the facility in 10/2023 with diagnoses including Congestive Heart Failure (a chronic condition in which the heart does not pump blood as well as it should) and a below the knee amputation. Review of Resident 5's clinical record revealed the following: - On 10/27/24 Resident 5 had a 4.9 pound weight gain in 24 hours. No evidence was found to indicate the physician was notified. - On 10/29/24 Resident 5 had a 10.2 pound weight gain in the past seven days. No evidence was found to indicate the physician was notified. - On 11/1 Resident 5 had a 4…

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 food preferences were honored for 1 of 3 sampled resident (#3) reviewed for food. This placed residents at risk for food lessened quality of life. Findings include: Resident 3 was admitted to the facility in 2020 with diagnoses including morbid obesity and diabetes. A 12/27/24 meal ticket revealed Resident 3 ordered barbecue country ribs, scalloped potatoes, mixed vegetables, fruit salad, two strawberry kiwi juices and two diet lemon sodas. On 12/27/24 at 12:21 PM, Resident 3 was observed eating lunch in her/his room and the meal consisted of barbecue country ribs, scalloped potatoes, and mixed vegetables. The resident received one strawberry kiwi juice and one diet lemon lime soda. There was only one beverage each and no fruit salad delivered with the meal. On 12/27/24 at 12:25 PM, Resident 3 stated she/he did not receive what she/he requested which occurred often. Staff 12 (CNA) was present and acknowledged the resident did not receive what she/he requested, and which was a…

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

Based on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include: 1. On 1/22/24 at 9:23 AM during the initial tour of the main kitchen, the following was observed regarding refrigerator two: -One plastic carton of moldy strawberries. -One container with a lid of sliced lemon wedges with no date. -One bag of sliced bread with a date, but not sealed. On 1/22/24 at 9:27 AM Staff 13 (Dietary Manager) confirmed the identified items were not appropriately stored. 2. On 1/24/24 at 11:31 AM Staff 24 (Cook/Dietary Aide) was observed to pick up a hamburger bun with ungloved hands and place it on the plate. She was observed to place a hamburger patty on the bun with tongs and then proceeded to move aside the hamburger bun with ungloved hands. The surveyor stopped Staff 24 and questioned why she was not wearing gloves. Staff 24 stated she forgot to put a pair on. Staff 13…

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 promptly respond to grievances and recommendations from the resident council for 4 of 4 months reviewed and ensure clothing and missing personal property were addressed timely for 2 of 3 sampled residents (#s 53 and 56) reviewed for personal property. This placed residents at risk for unresolved quality of life and care issues. Findings include: 1. The 6/2004 Grievance Policy indicated the Activities Director or designee was to complete a grievance form when a global issue was raised at a resident council meeting. The form was to be given to the appropriate department head for follow up and departments were to respond within five days. During a resident group meeting on 1/24/24 at 1:30 PM residents stated facility staff did not consistently respond to suggestions timely or concerns offered by the resident council. Residents indicated they did not feel staff communicated with them effectively and did not feel fully informed of the actions taken in response to their concerns. Resident Council Minutes from…

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 staffing to meet resident care needs for 4 of 4 halls reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 1/25/24 the facility provided lists of residents who: -Required assistance with eating: 5 -Required assistance with dressing: 49 -Required assistance with bathing: 58 -Required assistance with toileting: 52 -Required two-person assistance with transfers: 10 -Required mechanical lift transfers: 21 -Required incontinence care: 32 -Had wandering behaviors: 4 -Had behavioral healthcare needs: 18 Resident Council Notes were reviewed and indicated the following: 9/2023: call light response times were up to one hour and there were not enough staff to give showers. A lot of CNAs turned off call lights and stated they would be back, but never returned. 10/2023: Call light response times were still too long, staff indicated they would be back in a minute and never came back. 11/2023: Call light response was still an issue.…

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 appropriate medication storage temperatures were logged and maintained for 2 of 2 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 1/24/24 at 12:48 PM the medication refrigerator on the 200 hall was observed with Staff 27 (RN). Review of the refrigerator temperature log indicated temperatures were to be maintained between 36 to 46 degrees. The Logs from 1/1/24 through 1/24/24 revealed 20 instances with no temperatures logged. The medication refrigerator contained tuburculin (used for testing and diagnoses of Tuburculosis) and influenza vaccines (vaccines which require refrigeration). On 1/24/24 at 1:20 PM Staff 2 (Interim DNS) stated the medication refrigerator was to be checked twice a day (AM/PM). Staff 2 further stated there was not to be any holes in the temperature logs especially with vaccines in the medication refrigerators. 2. On 1/24/24 at 1:16 PM 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 residents' rights to a dignified existence and self-determination for 1 of 1 sampled resident (#56) reviewed for dialysis. This placed residents at risk for a diminished quality of life. Findings include: Resident 56 was admitted to the facility in 12/2023 with diagnoses including diabetes and end stage kidney disease. On 1/24/24 at 11:50 AM Resident 56 was observed in her/his wheelchair in the hallway talking to Resident 11. Both residents decided to eat lunch together and Resident 56 moved her/his bedside table next to Resident 11's door. Resident 11 received her/his lunch at 11:53 AM and started eating, but Resident 56's meal did not arrive. Resident 56 stated I never get my meals with the other residents. At 12:00 PM Resident 56 asked Staff 9 (CNA) and Staff 14 (LPN) about her/his lunch and stated I did not get my breakfast this morning either. Staff 9 told Resident 56 the kitchen lost her/his meal slip and asked Resident 56 what she/he wanted for lunch. Resident 56 requested a…

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

Based on interview and record review it was determined the facility failed to report results of abuse investigations to the State Survey Agency within the required time frame for 2 of 4 sampled residents (#s 34 and 49) reviewed for abuse. This placed residents at risk for abuse. Findings include: A 9/18/23 FRI for abuse involving a verbal abuse altercation when Resident 13 yelled at Resident 34 and Resident 49. The investigation was completed and submitted to the State Agency on 9/26/23 (three days late). On 1/25/24 at 1:59 PM Staff 2 (Interim DNS) acknowledged the facility investigation was not reported to the State Survey Agency within five working days.

Based on interview and record review it was determined the facility failed to provide bowel medications as ordered for 1 of 1 sampled resident (#16) reviewed for bowel care. This placed residents at risk for constipation. Findings include: The facility 10/2020 Bowel Care Protocol indicated the following: -If a resident has not had a bowel movement for three consecutive days, then evening shift was to run a report for residents who did not have a bowel movement. -Day shift was to administer milk of magnesia and if no results, then evening shift was to administer a suppository, if no results then, night shift was to administer a Fleets enema. Resident 16 admitted to the facility in 2019 with diagnoses including dementia. The 12/21/23 physician orders indicated Resident 16 was to receive a bisacodyl suppository every 24 hours PRN for constipation. Resident 16's 12/2023 and 1/2024 bowel records indicated the following days with no bowel movement: -12/29/23 -12/30/23 -12/31/23 -1/1/24 -1/2/24 -1/3/24 (Six days without a bowel movement) -1/8/24 -1/9/24 -1/10/24 -1/11/24 (Four days without…

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 address recommendations to promote wound healing for 1 of 2 sampled residents (#37) reviewed for pressure ulcers. This placed residents at risk for delayed healing and worsening of wounds. Findings include: The facility's 8/2020 Wound Management Policy and Guidelines indicated after the initial referral was sent to the Registered Dietitian, facility staff were to follow up on recommendations provided by the Registered Dietitian. Resident 37 admitted to the facility in 9/2020 with diagnoses including dementia and diabetes. The 9/6/23 Annual MDS indicated Resident 37 was at risk for pressure ulcer development. The resident's care plan for pressure ulcers, last updated 1/15/24, indicated the resident was at risk for pressure ulcers due to decreased mobility, incontinence of bowel, and comorbidities including diabetes. A 1/15/24 Progress Note indicated the resident was found to have two open areas on her/his coccyx (tail bone). 1/16/24 and 1/23/24 wound provider notes indicated the resident was assessed 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.

Based on observation, interview, and record review it was determined the facility failed to put services in place to eliminate the risk of elopement for 1 of 1 sampled resident (#48) reviewed for accidents. This placed residents at risk for elopement from the facility. Findings include: Resident 48 was admitted to the facility in 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing problems). A review of Resident 48's progress notes revealed Resident 48 had two prior elopement incidents at the facility on 8/26/22 and 8/27/23. On 9/1/23 Resident 48 received a new diagnosis of vascular dementia. A 9/4/23 Smoking Safety Evaluation revealed Resident 48 was independent to smoke and went to the designated smoking area outside. A FRI submitted on 9/11/23 revealed on 9/10/23 at 2:56 PM Resident 48 eloped from the facility from the smoking area at the back of the building. Resident 48 was located approximately 45 minutes later at a grocery store parking lot adjacent to the facility by Staff 16 (LPN RCM). 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 physician orders related to an ileostomy were followed and implemented for 1 of 1 sampled resident (#53) reviewed for ostomy care. This placed residents at risk for skin breakdown. Findings include: Resident 53 was admitted to the facility in 4/2023 with diagnoses including the presence of an Ileostomy (an artificial opening on the abdominal wall through which waste material passes out of the body from the bowel). Resident 53's 11/21/23 Care Plan indicated the resident was at risk for a potential infection related to an open wound on her/his abdomen, fistula and ileostomy status. Resident 53's Bowel Documentation records from 12/1/23 through 1/25/24 indicated the resident had output from her/his ileostomy which was loose or a diarrhea consistency. The Physician Order Summary as of 1/26/24 included the following order: - Change midline pouch, ileostomy pouch, and mucous fistula (attaches part of the intestine to a surgically created opening on the abdomen) dressing twice a week. -…

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 oxygen equipment was properly maintained for 1 of 1 sampled resident (#265) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 265 admitted to the facility in 1/2024 with diagnoses including chronic kidney disease. Observations from 1/22/24 through 1/25/24 revealed Resident 265 used an oxygen concentrator (generates medical-grade oxygen from surrounding air) through a nasal cannula (tubing with two prongs placed in nostrils). Resident 265's 1/2024 TAR indicated: - Oxygen one to four liters via nasal cannula PRN for comfort or shortness of breath. - Oxygen concentrator filters were to be changed or cleaned every four weeks for oxygen maintenance. - Change and date the oxygen nasal cannula tubing once weekly. Observations of the oxygen concentrator and oxygen tubing from 1/22/24 through 1/25/24 revealed: - the oxygen concentrator had a built-up layer of dust on the machine. - the two external filters on the oxygen…

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 five percent for 1 of 3 sampled residents (#14) reviewed for medication administration. The facility's medication error rate was 6.67%. This placed residents at risk for adverse medication consequences. Findings include: Resident 14 admitted to the facility in 4/2023 with diagnoses including respiratory failure and COPD (chronic obstructive pulmonary disease). Resident 14's 1/2024 physician orders included the following orders: - Advair Diskus (an inhaled combination medication to treat COPD) one puff two times a day; rinse mouth after every application. - Incruse Ellipta (an inhaled medication to treat COPD) one puff once a day; rinse mouth after every application. Advair Diskus manufacturer instructions indicated the user was to rinse their mouth with water without swallowing following inhalation to help reduce the risk of thrush (fungal infection in the mouth). On 1/24/24 at 7:05 AM Staff 25 (CMA) was observed to give Resident 14 the Advair Diskus…

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 proper placement of a resident's urinary catheter bag and appropriate infection control practices were in place for 2 of 2 sampled residents (#s 2 and 53) reviewed for infection control. This placed residents at risk for cross-contamination and infection. Findings include: 1. Resident 53 was admitted to the facility in 4/2023 with diagnoses including presence of an ileostomy (an artificial opening on the abdominal wall through which waste material passes out of the body from the bowel). On 1/22/24 at 9:35 AM Resident 53 was observed to have a towel covering her/his abdomen taped around the edges. On 1/23/24 at 1:08 PM Resident 53 stated the facility still did not have ostomy pouches available and she/he was noted to have a towel covering her/his abdomen secured with tape. On 1/23/24 at 1:45 PM Staff 14 (LPN) stated the resident kept a towel over her/his abdomen because the facility was out of ostomy pouches. On 1/25/24 at 1:41 PM Staff 6 (LPN) stated Resident 53 removed the last pouch…

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 and interview it was determined the facility failed to have the required Long Term Care Ombudsman (LTCO) poster posted for 1 of 2 floors observed for the LTCO poster. This placed residents and visitors at risk for not knowing how to reports concerns. Findings include: On 10/5/23 at 8:36 AM an observation of the first floor revealed the LTCO poster was not posted. On 10/5/23 at 8:36 AM Staff 9 (LPN) stated the first floor used to have the LTCO poster poster and verified the LTCO poster was no longer posted.

Based on observation, interview and record review it was determined the facility failed to ensure enough dietary personal was assigned each shift for 31 of 31 days reviewed for dining. This placed residents at risk for not getting preferences honored, being served the incorrect food and incorrect food textures. Findings include: A review of the August 2023 Dietary Staff Timecards revealed the following number of shifts worked over eight hours: *Staff 12 (Dietary Aide) - 15 shifts up to 14.75 hours * Staff 13 (Dietary Aide) - 9 shifts up to 8.5 hours * Staff 14 (Cook) - 10 shifts up to 13.75 hours * Staff 15 (Dietary Aide) - 4 shifts ranging up to 9 hours * Staff 17 (Hospitality Aide) - partial month, 2 shifts up to 10.5 hours * Staff 19 (Cook) - partial month, 3 shifts up to 8.75 hours * Staff 28 (Cook) - 16 shifts up to 15 hours * Staff 29 (Dietary Aide) - 19 shifts up to 15.25 hours On 8/30/23 at approximately 8:30 AM an observation with Staff 20 (Infection Preventionist) of the resident refrigerators on both the first and second floor revealed the temperatures were not checked 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 observation, interview and record review it was determined the facility failed to follow posted menu's for 2 of 2 meals observed for dining. This placed residents at risk for unmet dietary needs. Findings include: On 8/30/23 at 9:40 AM Staff 11 (Cook) stated she was not able to order the food she needed because she had to stay within budget which resulted in the facility not serving the food on the menus because they did not have the needed food. Staff 11 stated the days menu listed chicken carbonara but the facility did not have the sauce or tortilla's so they would substitute chicken alfredo with rice and refried beans instead. Staff 11 further stated the residents were tired of the food offerings and wanted more of a variety. Staff 11 stated residents mostly received broccoli or green beans for vegetables. On 9/1/23 at 8:25 AM Staff 10 (CNA) verified the breakfast tray ticket listed pancakes, syrup, oatmeal, bacon strips, mixed fruit cup and drinks as the menu items. Staff 10 verifed the resident food trays did not include bacon and the mixed fruit cup was substituted…

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 provide a safe, comfortable and homelike environment for 2 of 2 floors reviewed for environment. This placed residents at risk for an unclean and unsafe environment. Findings include: 1. The 4/27/23 and 5/31/23 Resident Council Notes revealed the residents verbalized concerns related to unclean bathrooms, cob webs, odor and sticky floors. On 8/30/23 at approximately 8:30 AM an environmental observation of the facility was started with Staff 20 (Infection Preventionist). The following concerns were identified: Second Floor: *205 - The floor was dirty, had black tire track marks throughout room and dirt marks on wall. *206 - The floor and wall was dirty, black marks all over the floor, duct tape on floor and paint peeling off wall behind both beds. *208: The floors were dirty with black lines on floor and the windowsill was scratched up. *210: There were black lines on floor. *212: The floors were dirty with cracked linoleum…

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 and interview it was determined the facility failed to maintain the exterior safety railing for 1 of 1 buildings reviewed for accident hazards. This placed residents, visitors and staff at risk for serious injury. Findings include: On 8/23/23 at approximately 9:00 AM two residents were observed to be in the sitting in their wheelchairs on the front sidewalk. The residents did not touch the safety railing. On 8/23/23 at 11:30 AM Resident 3 was observed in her/his wheelchair on the front sidewalk. The resident did not touch the safety railing. From 8/23/23 through 9/7/23 the outside metal staircase to walk down to the first floor (and is attached to the safety railing) had yellow caution tape around it. On 9/7/23 at 8:18 AM the safety railing parallel to the parking lot and alongside the sidewalk was found to have two large sections where the railing was not secure and able to be easily pushed in toward the hill that it was protecting residents, visitors and staff from falling down. The north side of the building had approximately six to seven loose sidewalk…

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 clean, safe drinking water was served to the residents on 1 of 2 floors (2nd floor) observed for dining services. This placed residents at risk of food-borne illness. Findings include: The 4/27/23 and 5/31/23 Resident Council Notes revealed cobwebs in the bathrooms and overall the bathrooms need attention. On 8/30/23 at 8:05 AM a general observation of the second resident rooms was conducted. The bathrooms were dirty and in need of cleaning. On 9/7/23 at 7:35 AM room [ROOM NUMBER] was observed to have plastic, disposable water bottles in the room. On 9/7/23 at 7:40 AM an observation of the second floor revealed no public drinking water station and no sinks to obtain water from in the public areas. On 9/7/23 at 7:35 AM Staff 10 (CNA) and Staff 24 (CNA) stated the only place staff could get water for the residents was the bathroom sink. Staff 10 stated the facility previously had a water station but staff were told it…

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 notify the resident representative of a hospital transfer for 1 of 3 sampled residents (#1) reviewed for notifications. This placed resident representatives at risk for being uninformed of current resident status. Findings include: Resident 1 admitted to the facility in 2015 with diagnoses including end stage renal disease. The 7/12/23 Discharge Summary indicated Resident 1 was transferred to the hospital from the dialysis facility. Review of Resident 1's medical record revealed no evidence Resident 1's representative was notified of the hospital transfer on 7/12/23. On 8/23/23 at 5:00 PM Witness 1 (Complainant) stated Resident 1 was transferred to the hospital and she/he was not notified. On 8/23/23 at 11:30 AM Staff 4 (LPN Resident Care Manager) verified Resident 1's representative was not notified of the hospital transfer on 7/12/23.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation for 4 of 6 sampled residents (#s 2, 16, 17 and 18) reviewed for abuse. This placed residents at risk for financial abuse. Findings include: Resident 2 was admitted to the facility in 2021 with diagnoses including dementia. Resident 16 was admitted to the facility in 2022 with diagnoses including hypertension. Resident 17 was admitted to the facility in 2022 with diagnoses including diabetes. Resident 18 was admitted to the facility in 2022 with diagnoses including convulsions. The 8/17/23 facility records indicated Resident 2 reported she/he and three other residents loaned Staff 21 (CNA) money and did not get paid back. The 8/17/23 Facility Investigation indicated Resident 2 loaned Staff 21 twenty dollars and did not get the money back. Resident 16 indicated Staff 21 asked her/him for one hundred dollars as he did not have money for food, Resident 16 loaned it to him but did Staff 21 did not pay the money. Resident 17 requested Staff 21 give twenty dollars…

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 revise a residents plan of care for 1 of 2 sampled residents (#18) reviewed for dining. This placed residents at risk for lack of food. Findings include: Resident 18 re-admitted to the facility in 2022 with diagnoses including depression. The current Nutrition Care Plan revealed an 11/24/20 intervention which indicated Resident 18's family would bring in lunch and dinner. The 11/27/20 intervention instructed staff to check with Resident 18 to ensure her/his family brought in lunch and dinner, if not to notify the kitchen daily. Records revealed Resident 18's family was out of state and unable to bring the resident lunch and dinner. On 9/7/23 at 2:12 PM Staff 2 (DNS) stated the family member lives out of state every summer and the care plan needed to be updated.

Based on interview and record review it was determined the facility failed to ensure services provided met professional standards of quality for 5 of 7 sampled residents (#s 2, 3, 16, 17 and 18) reviewed for medications and abuse. This placed residents at risk for missed medications and financial abuse. Findings include: 1. Resident 3 admitted to the facility in 2022 with diagnoses of diabetes and glaucoma. The 7/17/23 Facility Records indicated Resident 3 requested her/his medications, Staff 22 (LPN) did not understand Resident 3's Spanish so told the resident to return to their room and to speak English, not Spanish. Resident 3 stated Staff 22 did not administer the medications and documented she/he refused the medications which she/he did not. The July 2023 MARs revealed the following 8:00 PM and 9:00 PM medications documented as refused: *Lidocaine External Patch 4%, remove per schedule (pain patch) *Systane Nighttime Ophthalmic Ointment. (artificial tears eye drops) *Xalantan Ophthalmic sol 0.005% (glaucoma eye drops) *Brimonidine Tartrate Ophthalmic sol 0.2% (glaucoma eye…

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 administer medications as ordered for 2 of 3 sampled residents (#s 1 and 3) reviewed for medications. This placed residents at risk for worsening medical symptoms. Findings include: 1. Resident 1 admitted to the facility in 2015 with diagnoses including hypertension and end stage renal disease. The 7/20/23 Physician Order instructed to administer Midodrine HCL 10 mg tablet every six hours and to hold for systolic blood pressure greater than 110. The July 2023 MARs revealed the Midodrine was administered as ordered on 7/28/23. The medication instructed to administer one 10 mg tablet (not two tablets). The 7/28/23 Facility Investigation revealed Staff 5 administered two tablets instead of one of Midodrine to Resident 1 on 7/28/23. The bubble pack (medication dispensing form) for the Midodrine had 2 tablets inside each bubble pack. The directions indicated to give 10 mg; it did not indicate the dosage of each tablet. The CMA immediately reported the medication error, and both the pharmacy and physician were…

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 it was determined the facility failed to serve residents the correct texture food for 1 of 1 kitchens reviewed for dining. This placed residents at risk for aspiration. Findings include: On 8/30/23 Staff 11 (Cook) due to staffing concerns residents were sent out food with the wrong tray tickets and not getting the correct texture as ordered. Staff 11 offered an example from the day prior when a resident was given taquitos and the tray was returned to the kitchen because it was the wrong texture. On 9/7/23 at 7:45 AM Staff 10 (CNA) stated dietary gave a resident who was on a regular puree diet the wrong textured food. The CNA discovered the error before the resident started to eat. On 9/7/23 at 8:26 AM Staff 18 (Dietary Aide) verified residents were sometimes getting the wrong tray card on their tray and occasionally trays were sent out with the incorrect texture.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure a residents food preferences were honored for 2 of 3 sampled residents (#s 6 and 18) reviewed for dining. This placed residents at risk for weight loss and malnutrition. Findings include: 1. Resident 18 was readmitted to the facility in 2022 with diagnoses including depression. The current Nutrition Care Plan revealed a 9/7/21 revision for the resident to have vanilla or chocolate ice cream at every meal. The 8/5/22 Nutrition Assessment indicated Resident 19 received two ice creams with each meal. On 8/30/23 Staff 11 (Cook) stated the dietary staff was understaffed, they were not getting the food they needed because they had to stay within budget and verified food was sent out with the wrong try tickets/food. On 9/7/23 at 7:20 AM Staff 22 (CNA) stated the dietary staff are frequently making mistakes on the food trays. Staff 22 stated the resident dislikes were missed or the residents did not receive what they asked for. Staff 22…

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

Based on interview and record review it was determined the facility failed to accurately document in the medical record for 1 of 3 sampled residents (#3) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 3 admitted to the facility in 2022 with diagnoses of diabetes and glaucoma. The 7/17/23 Facility Records indicated Resident 3 requested her/his medications, Staff 22 (LPN) did not understand Resident 3's Spanish so told the resident to return to their room and to speak English, not Spanish. Resident 3 stated Staff 22 did not administer the medications and documented she/he refused the medications which she/he did not. The July 2023 MARs revealed the following 8:00 PM and 9:00 PM medications documented as refused: *Lidocaine External Patch 4%, remove per schedule (pain patch) *Systane Nighttime Ophthalmic Ointment. (artificial tears eye drops) *Xalantan Ophthalmic sol 0.005% (glaucoma eye drops) *Brimonidine Tartrate Ophthalmic sol 0.2% (glaucoma eye drops) *Cosopt Ophthalmic sol 22.3-6/8 mg/ml (glaucoma eye drops)…

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 interview it was determine the facilty failed to ensure resident equipment was in good working order for 2 of 2 floors reviewed for equipment. This placed residents at risk for accidents and injuries. Findings include: 1. The August 2023 maintenance records revealed Resident 19's bed had multiple work order requests for the bed to be fixed. On 8/29/23 at 10:57 AM Staff 10 (CNA) stated Resident 19's bed was broken, the foot of the bed would not go up, the resident would slide down and need to get boosted up three to four times each shift. The issue was put into the maintenance event log system several times but the bed had still not been fixed. On 8/29/23 at 11:07 an observation was completed of Resident 19's bed with Staff 3 (Regional RN). The bottom of the bed was at a lower angle. An unsuccessful attempt was made to move the foot of the bed up. Staff 3 verified Resident 19's bed was not in good working order as the foot of the bed was not level with the rest of the bed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to ensure call lights were answered timely and bathing was completed for 1 of 2 floors (first floor) reviewed for staffing. This placed residents at risk for lack of hygiene and delayed care. Findings include 1. Resident Council Notes for 9/2022 and 10/2022 were reviewed with Staff 17 (Activities) and revealed the residents reported long call light response times. On 11/2/22 at 3:15 PM room [ROOM NUMBER]'s call light was activated by the resident. At 3:30 PM non-nursing staff entered the resident's room and the resident stated she/he was waiting for her/his CNA. At 3:47 PM, 32 minutes later, Staff 15 (CNA) entered the resident's room. At 11/2/22 at 3:54 PM Staff 15 stated she was assisting another resident with bathing and she was not able to answer the call light for room [ROOM NUMBER]. Staff 15 stated her/his hall partner was split between the first and second floor and the hall partner was not…

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 and interview it was determined the facility failed to keep a bathroom call light at accessible length for 1 of 1 sampled resident (#40) reviewed for environment. This placed residents at risk for not being able to call for assistance in the event of a fall. Findings include: Resident 40 admitted to the facility in 2022 with diagnoses including post-traumatic stress disorder. Resident 40 resided in room [ROOM NUMBER]. The 9/2/19 Care Plan indicated Resident 40 was independent to moderate assistance with toileting. The Care plan indicate the resident was a moderate risk for falls related to weakness. On 10/31/22 at 12:30 PM the call light cord in the bathroom between rooms [ROOM NUMBERS] was observed to be about eight inches long and not able to be reached from the floor level. On 11/4/22 at 11:45 AM the call light cord in the bathroom was observed to be short and frayed at the end. The cord measured seven inches long. Staff 20 (CNA) stated Resident 40 used the bathroom independently. 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 interview and record review it was determined the facility failed to provide a written notification to 2 of 4 sampled residents (#s 53 and 264) reviewed for Beneficiary Protection Notices. This placed residents at risk for unknown financial liabilities. Findings include: 1. Resident 53 was admitted to the facility with Medicare Part A services (skilled services including therapy) on 7/21/22. The resident's last covered day of Part A services was 10/5/22 with the facility issuing a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) letting the resident know of potential financial liability because Resident 53 remained in the facility after Medicare Part A ended. There was no documentation indicating Resident 53 was issued a Notice of Medicare Non-Coverage (NOMNC) which notified the resident skilled services were ending and their right to an appeal. On 11/2/22 at 1:58 PM Staff 5 (Social Services) stated she issued both the NOMNC and SNF ABN at the time of Resident 53's discharge from skilled services however she was unable to provide documentation…

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.

1. Based on observation and interview it was determined the facility failed to ensure comfortable sound levels were maintained in 1 of 2 halls (North Hall) for 3 residents (#s 13, 29 and 44) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: From 10/31/22 through 11/3/22 the following observations were made from the hall and with residents present both in the hallway and in rooms with open doors: - 10/31/22 at 11:30 AM Resident 21 was sitting up in a wheelchair and was yelling out while in her/his room. One staff came into room and the resident continued to yell once the staff left the room. -10/31/22 at 12:04 PM the resident was yelling. -11/2/22 from 11:13 AM to 11:20 AM the resident was up in the wheelchair yelling off and on in a high pitch with periods of laughing. A staff was observed attempting to distract the resident, once the staff left the resident continued to yell. -On 11/2/22 at 11:13 AM Resident 13 was in her/his room (next to Resident 21) and heard Resident 21 yelling out and told the resident to shut up. 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 interview and record review it was determined the facility failed to accurately code the MDS for 2 of 3 sampled residents (#s 19 and 62) reviewed for hospitalizations and vision. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 19 admitted in 2022 with diagnoses including diabetes. Resident 19's 9/2022 admission MDS indicated she/he had mild cognitive impairment, and her/his vision was adequate with corrective lenses. On 11/2/22 at 12:55 PM Staff 9 (LPN Resident Care Manager Assistant) stated she was unaware Resident 19 had glasses and did not believe she/he wore glasses. On 11/4/22 at 2:00 PM Staff 2 (DNS) and Staff 3 (Corporate RN) were provided this information and affirmed the MDS was likely coded in error. 2. Resident 62 admitted to the facility in 2022 with diagnoses including adult failure to thrive. The 8/7/22 Discharge Return not Anticipated MDS coded Resident 62 as discharging to an acute hospital. An 8/7/22 progress note indicated Resident 62 discharged home. On 11/3/22 at 2:50 PM Staff 6 (RN, MDS Coordinator) confirmed 62'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 address vision needs in a timely manner for 1 of 2 sample residents (#19) reviewed for vision needs. This placed residents at risk impaired interaction with staff and the environment. Findings include Resident 19 admitted in 2022 with diabetes. Resident 19's 9/2022 admission MDS indicated she/he had mild cognitive impairment, and her/his vision was adequate with corrective lenses. On 10/31/22 at 11:00 AM Resident 19 stated she/he needed a vision appointment, but no one talked to her/him about this. A review of Resident 19's medical record revealed no documentation that indicated any steps were taken including offering services, contacting family, or making an appointment, to manage her/his vision needs. On 11/2/22 at 12:55 PM - Staff 9 (LPN Resident Care Manager Assistant) stated normally we try to schedule residents with services promptly. Staff 9 confirmed this did not occur for Resident 19.

Based on observation, interview and record review it was determined the facility failed to ensure the facility applied a splint for a resident with impaired ROM for 1 of 2 sampled residents (#28) reviewed for ROM. This placed residents at risk for pain. Findings include: Resident 28 was admitted to the facility in 2020 with diagnoses including dementia. A 1/2/22 OT Evaluation and Plan of Treatment form revealed the resident had a contracture of the left hand. The goal was for the resident to tolerate daily positioning with custom splinting to reduce contractures. On 10/31/22 at 11:48 AM a sign was observed to be posted in Resident 28's room above her/his bed. The sign was dated 1/2/22 and indicated the resident was to have a left hand splint. The splint was to be worn for four hours and was to be removed for one hour during the day or if the splint was not used gauze was to be placed under the fingers. A 10/2022 TAR revealed a left hand splint was applied at 8:00 AM on 10/1/22 and removed at 8:00 PM on 10/1/22. The treatment was discontinued after 10/1/22. A Care Plan updated 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 resident received sufficient fluid intake and failed to follow RD recommendations for nutritional supplements for 3 of 4 sampled residents (#s 1, 25 and 49) reviewed for hydration and nutrition. This placed residents at risk for dehydration and weight loss. Findings include: 1. Resident 1 was admitted to facility in 2/2019 with diagnoses including diabetes and functional quadriplegia (complete immobility due to severe physical disability or frailty). The 9/26/22 Annual MDS indicated Resident 1 required extensive assistance, one-person with eating/drinking and had range of motion impairment to both her/his upper and lower extremities. Resident 1's 10/5/22 Care Plan included potential for fluid deficit related to dependence on staff for fluids. Interventions included hydration pass and assistance with intake. On 10/31/22 at 11:36 AM Witness 2 (Family) reported Resident 1's skin and lips were often dry and stated a request was made to the facility to offer Resident 1 hydration in between meals. When…

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 observations, interview and record review it was determined the facility failed to re-evaluate, assess and implement interventions of behavioral needs for 1 of 1 sampled resident (#21) reviewed for behavior/emotional health. This placed residents at risk for unmet psychosocial well being. Findings include: Resident 21 admitted to the facility in 2018 with diagnoses including Alzheimer's Disease, schizophrenia, depression and altered mental status. From 10/31/22 through 11/3/22 the following observations were made from the hall and with residents present both in the hallway and residents' room: -10/31/22 at 11:30 AM Resident 21 was sitting up in a wheelchair and was yelling out while in her/his room. One staff came into the room and the resident continued to yell once the staff left the room. - 10/31/22 at 12:04 PM the resident continued to yell. - 11/2/22 from 11:13 AM to 11:20 AM the resident was up in the wheelchair yelling off and on in a high pitch with periods of laughing. Staff were observed attempting to distract the resident. Once the staff left the 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 a resident was assisted in obtaining timely dental services for 2 of 4 sampled residents (#s 19 and 32) reviewed for dental services. This placed residents at risk for worsening dental status. Findings include: 1. Resident 32 was admitted to the facility in 2022 with diagnoses including heart disease. A 5/21/21 Significant Change MDS indicated the resident was discharged from hospice. The resident was assessed to have broken front teeth, likely had cavities but denied pain. The resident was able to eat as desired. A Care Plan initiated in 2020 indicated the resident had dental health problems related to missing and broken teeth and staff were to coordinate arrangements for dental care as needed. The resident's record revealed dental services were not provided until 10/13/22. Resident 32's 10/13/22 dental visit summary note revealed the plan was to remove non-fixable decayed teeth and make a partial. On 11/3/22 at 9:24 AM Staff 5 (Social Services Director) stated if a resident 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 interview and record review it was determined the facility failed to ensure residents' medical records were complete and accurate for 2 of 7 sampled residents (#s 15 and 19) reviewed for care planning and unnecessary medications. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 15 admitted in 2022 with diagnoses including major depression. Resident 15 had a prescription for Aripiprazole 5 mg which was reduced via gradual dose reduction (GDR) from 10 mg on 7/4/2021. Documentation revealed there was no subsequent GDR attempted. On 11/4/22 at 11:30 AM Staff 9 (LPN care manager) located documentation that indicated Resident 15 was not on Aripiprazole from 4/29/22 through 5/3/22. On 11/4/22 at 1:30 PM Staff 3 (Corporate RN) located documentation indicating a GDR attempt that was not carried out due to Resident 15 discharging to the hospital in 4/2022. Staff 3 confirmed none of the information provided by Staff 9 or herself was locatable in the medical record. 2. Resident 19 admitted in 2022 with diagnoses including major depressive…

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.