Capitol Rehabilitation And Healthcare Center

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 10 residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included anxiety disorder (excessive fear or apprehension about real or perceived threats) and depression (persistent feelings of sadness, loss of interest in activities, and a range of emotional, physical and cognitive symptoms). Review of Resident 2's clinical record revealed she was ordered Lorazepam 0.5 milligrams (mg) one time daily for anxiety for six months, with a start date of November 4, 2024 and Lorazepam 0.5 mg every 12 hours as needed (PRN). Review of Resident 2's May 2025 medication administration record (MAR) revealed Resident 2's daily Lorazepam order stopped on May 3, 2025 and a new order did not start until May 13, 2025. Review of the controlled drug record for the Resident 2's Lorazepam revealed Employee 1 continued to sign out the medication for six days after…

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for one of six residents reviewed (Resident 1). Findings include: Review of facility policy, titled Weight Assessment and Intervention, last reviewed March 29, 2025, read, in part, Resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Care planning for weight loss or impaired nutrition is a multidisciplinary effort. Individualized care plans shall address the identified cause of weight loss, goals 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 record review and staff interview, it was determined that the facility failed to document physician ordered medication administrations in the clinical record for one of seven residents reviewed (Resident 6). Findings include: A review of the clinical record for Resident 6 revealed diagnoses that included Type 2 Diabetes Mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (elevated blood pressure). Further review of the clinical record revealed that Resident 6 was admitted to the facility on [DATE], post-hospitalization for sepsis (bacterial blood stream infection). The Resident was admitted with a PICC (peripherally inserted central catheter) to administer intravenous medications. The Medication Administration Record (MAR) for Resident 6 revealed the following intravenous (IV) flushes were not signed off as completed: Sodium Chloride 0.9%, use 10 milliliters (ml) to flush IV for PICC maintenance on December 28, 2024,…

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, clinical record review, and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of five residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and anxiety disorder (a persistent feeling of worry, nervousness, or unease). Observation of Resident 1 on December 23, 2024, at 11:47 AM, revealed he was sitting in a dining area with other residents, and a yellow puddle consistent with urine appeared underneath his chair. Further observation in the dining area on December 23, 2024, at 12:10 PM, revealed Resident 1 wheeling away from the dining area and Employee 1 (Nurse Aide) wheeled him back over to the table where he 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 facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's comprehensive plan of care for one of five residents reviewed (Resident 1). Findings include: Review of facility policy, titled Perineal Care, last revised February 2018, read, in part, The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Review of Resident 1's clinical record revealed diagnoses that included benign prostatic hyperplasia (BPH- a condition in which the flow of urine is blocked due to the enlargement of prostate gland), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and anxiety disorder (a persistent feeling…

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 clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 25 residents reviewed (Residents 11, 17, 91, and 101). Findings include: Review of Resident 11's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and age-related osteoporosis (occurs when bones become weaker and more fragile due to the aging process). Further review of Resident 11's clinical record revealed that Resident 11 had a fall on February 18, 2024, without injury. A review of Resident 11's Quarterly MDS (minimum data set-periodic assessment) dated April 16, 2024, was marked for a fall with major injury. Further review of the clinical record failed to reveal any documentation of a fall with major injury. The clinical record for Resident 11 revealed that on April 4, 2024, 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 facility policy review, observation, clinical record review, and resident representative and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 25 residents reviewed (Residents 65, 102, 106, and 113), and failed to give the opportunity to participate in the development, review, and revision of his/her care plan for four of 25 residents reviewed (Residents 41, 73, 91, and 101). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revised date of March 2022, and last review date of June 17, 2024, read, in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal…

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 clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice when administering medications for five of 22 residents reviewed on the East Wing (Residents 11, 21, 43, and 55), and that physician orders are discontinued for one of 25 residents reviewed (Resident 99). Findings Include: Review of Resident 11's clinical record revealed diagnoses that included hypothyroidism (thyroid doesn't produce enough thyroid hormone) and age-related osteoporosis (occurs when bones become weaker and more fragile due to the aging process). A review of Resident 11's clinical record revealed she was ordered Levothyroxine 75 mcg (micrograms) daily at 6:00 AM. A review of Resident 11's medication administration record failed to reveal that the medication was initialed by Employee 10 as administered on October 6, 2024, at 6:00 AM. Review of Resident 21's clinical record revealed diagnoses that included hypothyroidism (thyroid doesn't produce enough thyroid hormone) and…

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

Based on facility policy review, clinical record review, facility document review, and resident and staff interviews, it was determined that the facility failed to administer the correct dosage of medication for one of 25 residents reviewed (Resident 41); and failed to ensure that physician's orders were implemented for three of 22 residents on the East Wing (Residents 69, 87, 89). Findings include: A review of the facility policy, titled Administering Medications, last revised April 2019, revealed that the individual administering the medications records in the resident's medical record; the date and the time the medication was administered; the dosage; the signature and title of the person administering the medication. The individual administering medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. Review of Resident 41's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked…

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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed for dialysis (Resident 77). Findings include: Review of facility policy, titled End stage renal disease, Care of a Resident with, last revised September 2010, read, in part, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Education and training of staff includes, specifically: The nature and clinical management of ESRD; The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: How information will be exchanged between the facilities. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of Resident 77's clinical record revealed diagnoses…

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 observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records are in order and that account of all controlled drugs is maintained and periodically reconciled for three of three residents reviewed (Resident 63, 117, and 119). Findings include: Review of facility provided policy, Discarding and Destroying Medications, revised [DATE], revealed, 10. The medication disposition record contains, as a minimum, the following information: a. The resident's name. b. The name and strength of the medication. c. The prescription number (if any). d. The name of the dispensing pharmacy. e. Date medication destroyed. f. The quantity destroyed. g. Method of destruction. h. Reason for destruction. i. Signature of witnesses. 11. Completed medication disposition records are kept on file in the…

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

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 91). Findings include: Review of facility policy, titled Dressings, Dry/Clean, with a last revised date of September 2013, and a last review date of June 17, 2024, revealed, in part, Steps in Procedure 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 17. Apply the ordered dressing. Also, section titled Documentation indicated The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed; 3. The name and title (or initials) of the individual changing…

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 facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to monitor hydration status precisely and effectively for one of 25 residents reviewed (Resident 14). Findings include: Review of facility policy, titled Encouraging and Restricting Fluids, last revised October 2010, read, in part, The purpose of this procedure is to provide the resident with amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Review the resident's care plan and/or your daily assignment sheet to assess for any special needs of the resident. Follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake. Review of Resident 14's clinical record revealed diagnoses that included congestive heart failure (CHF- a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and hypertension…

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 clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for five of 28 residents reviewed (Resident 17, 35, 39, 94, and 119). Findings Include: Review of Resident 17's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems) and dependence on supplemental oxygen (cannot live with supplemental oxygen). Review of Resident 17's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 26, 2023, Section O0100. Special Treatments, Procedures, and Programs, C1. Oxygen Therapy revealed that Resident 17 did not receive oxygen therapy during the previous 14 days. Review of Resident 17's electronic medical record, in a section labeled vital signs, revealed that Resident 17 had been using…

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 clinical record review, observations, and staff and resident interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for five of 28 residents reviewed (Resident 113, 335, 371, and 372). Findings include: Review of Resident 113's medical record revealed diagnoses that included: peripheral vascular disease (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel, osteomyelitis (infection of the bone), and muscle weakness Review of Resident 113's physician orders revealed an order for Heel lift boots to bilateral feet every shift, with a start date of December 11, 2023. Review of Resident 113's care plan on December 18, 2023, revealed a focus area I have impaired skin integrity and am at risk for pressure areas (pressure area/PU- wound that occurs related to prolonged pressure against the skin) related to PU L heel, recent toe amputation on right foot, malnutrition, Left Heel Stage 1 initiated October 30,…

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, review of meal extension sheets (forms that reveal what foods and quantities should be served to each diet), and staff and resident interviews, it was determined that the facility failed to ensure therapeutic diets (meal plans that control the intake of certain foods or nutrients) were provided for the lunch meal on December 20, 2023. Findings include: Review of the meal extension sheets revealed that residents on therapeutic diets including the consistent carbohydrate diet, heart healthy diet, and 2 gram sodium diets, should have been served 4 ounces (oz - unit of measure) of soup rather than 6 oz. Further review of the meal extension sheets revealed that residents on the therapeutic diets including the renal diet, heart healthy diet, and 2 gram sodium diets, should be served spaghetti and meatballs without sauce, and served 1 oz of low sodium gravy instead. Observation of lunch meal tray line on December 20, 2023, at 12:19 PM, revealed Resident 40 was prescribed a 2 gram sodium diet, was served spaghetti and meatballs with tomato sauce, and was not served…

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 clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one of 28 residents reviewed (Resident 330). Findings include: Review of Resident 330's clinical record revealed diagnoses that included essential hypertension (high blood pressure) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Review of Resident 330's clinical record reveals they were admitted on [DATE], from [NAME] State Health Rehabilitation Hospital. Review of clinical records received from [NAME] State Health Rehabilitation Hospital revealed Resident 330 had a stage four sacral pressure ulcer, with an onsite date of October 30, 2023. Review of a skin and wound evaluation completed on Resident 330 on December 14, 2023, revealed wound measurements with a length…

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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 26 residents reviewed (Residents 3 and 113). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revised date of March 2022, and last review date of June 2023, revealed: 11. Assessments of residents are ongoing and care plans are revised as information about the residents' conditions change. Review of Resident 3's clinical record revealed diagnoses that included type II diabetes (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin), heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), and hypertension (high blood pressure). Review of Resident 3's care plan revealed a care plan focus that indicated I am currently being treated for Shingles (a viral disease characterized by a painful skin rash with blisters in a localized area), with…

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 facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive services consistent with professional standards of practice and the comprehensive person-centered care plan for one of one resident reviewed (Resident 80). Findings include: Review of facility policy, titled End Stage Renal Disease, Care of a Resident, (undated) with a last review date of June 2023, revealed, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents. Review of Resident 80's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), end stage renal disease (ESRD - condition in which a person's kidneys cease…

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 surveyor observation, facility policy review, and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards, including refrigeration, for one of two medication rooms observed (South Hall). Findings Include: Review of facility policy titled, Medication Labeling and Storage, with revision date of February 2023, revealed Multi-dose vials that have been opened or acceded (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. An observation of a medication storage room in the South Hall, on December 20, 2023, at 12:01 PM revealed medication refrigerator number four contained one open vial of Aplisol (diagnostic agent used to test for Tuberculosis) with no open date and one open vial of Alfuia (Influenza vaccine) with no open date. Licensed Practical Nurse 13 (LPN 13), confirmed the vials should have been dated when opened and she removed the vials from refrigerator four. Further observation of…

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 review of resident council meetings and resident grievance, completion of meal test tray, review of select facility test tray form, and resident and staff interviews, it was determined that the facility failed to provide foods that were at appetizing temperatures at one of one meals. Findings include: Review of facility document, titled Test Tray, revealed that hot foods and hot beverages should be served at or above 135 degrees Fahrenheit (F - a unit of measure), and cold foods and beverages should be served at or below 41 degrees F. Interview with Resident 373 on December 18, 2023, at 10:03 AM, revealed her food is often served cold. Interview with Resident 372 on December 18, 2023, at 11:47 AM, revealed the food is often served cold. Review of facility grievance logs revealed Resident 373 filed a grievance on December 10, 2023, about her food being cold and, when the facility inquired if it was an isolated incident, she stated sometimes her food is cold. Review of November 2023 Food Committee Meeting minutes revealed Resident 105 complained his soup is served cold.…

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, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by wearing required PPE (personal protective equipment) on two of three employees observed (Employees 1 and 2). Findings Include: Review of facility policy, titled Isolation - Categories of Transmission-Based Precautions, with a revision date of September 2022, revealed in a section labeled Contact Precautions, 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Observation of Resident 18's room on December 18, 2023, at 10:00 AM, revealed a PPE container hanging on the door and a sign that said…

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.