Valley View Rehab And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, clinical record review, and staff and resident interview it was determined that the facility failed to ensure the highest practicable care for three of 35 residents reviewed (Residents 40, 230, and 94). Findings include: The facility policy entitled, Verbal, Telephone, and Written Physician Orders, last reviewed November 21, 2024, revealed that a physician's verbal or telephone order will be given to a licensed nurse and be immediately recorded on the resident's medical record by that licensed nurse. Telephone orders for medical treatment will be accepted only under circumstances where it is impractical for the orders to be given in a written manner by the responsible practitioner, when the judgement of the professional nurse and the situation requires expedient action, or when the physician calls the facility and requests that a telephone order be accepted. The facility policy entitled, Skin Tears, Risk Reduction, last reviewed November 21, 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 review of select facility policies, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to assess for the risk of side rail entrapment for 6 of 7 residents reviewed for accident hazards (Residents 14, 44, 85, 102, 113, and 230). Findings include: Review of the facility's current policy entitled Maintenance Enabler Bar Procedure last reviewed November 20, 2024, revealed it is the facility policy that maintenance will place assist bars on the resident's bed and immediately conduct a bed inspection for bed entrapment points using a bed measurement device following the manufacturer's test methods to inspect each zone. The zones were not specified. Observation of Resident 102's room on May 20, 2025, at 10:51 AM revealed an enabler bar attached to the right side of the resident's bed. Resident 102 stated it was put there to help her in bed because she had falls. Review of facility documents revealed facility staff completed an enabler bar entrapment evaluation for Resident 102 on March 14, 2025, which revealed facility…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of five residents reviewed (Residents 72 and 86). Findings include: Clinical record review revealed the facility admitted Resident 72 on January 24, 2025. Review of a consultant pharmacist recommendation dated April 12, 2025, revealed as needed Ativan (an antianxiety medication) is the most effective intervention for reducing Resident 72's anxiety. The pharmacist recommended Ativan 0.5 milligrams (mg) every 12 hours as needed for anxiety for 30 days with a re-evaluation of Resident 72's Ativan use in 30 days to determine if ongoing use is indicated. Review of Resident 72's clinical record revealed a physician's order dated April 16, 2025, for Ativan 0.5 mg, one tablet every 12 hours as needed for agitation. Further clinical record review revealed that Resident 72's order for Ativan did not have a 14 day stop date and there was no physician's progress note that provided a rationale for 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 clinical record review and staff interview, it was determined that the facility failed to revise the comprehensive care plan for one of 35 residents reviewed (Resident 11). Findings include: Observation of Resident 11 on May 21, 2025, at 9:10 AM revealed a urinary collection bag hanging from the left side of his bed. Clinical record review for Resident 11 revealed an active physician's order dated May 19, 2025, for the use of a Foley catheter (flexible tubing inserted through the penis into the bladder to drain urine) due to urinary retention related to bladder cancer. The order instructed staff to change the Foley as needed for obstruction, leaking, or if the closed system is compromised. Review of active plans of care for Resident 11 (including a care plan to address Resident 11's risk for urinary retention, incontinence, chronic kidney disease, and urinary tract infection) during the onsite survey revealed no plan of care that included the intervention of an indwelling Foley catheter. The surveyor reviewed the above concerns regarding Resident 11's care plans during an…

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 a review of select facility policies and procedures, facility documentation, clinical record review, employee personnel record information, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to obtaining verbal or telephone physician orders for one of one employee reviewed (Employee 3; Resident 40). Findings include: The Centers for Medicare and Medicaid Services (CMS) QSO-24-13-NH memo dated June 18, 2024, noted that requirements specify that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by two of four residents reviewed (Residents 86 and 89). Findings include: Clinical record review for Resident 86 revealed that the facility admitted her on November 25, 2024, with diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 86's significant change minimum data set (MDS, a form completed at specific intervals to determine care needs) assessment dated [DATE], indicated that the facility assessed Resident 86 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 86's care plan entitled, Impaired cognitive function/dementia or impaired thought processes r/t (related to) Vascular Dementia initiated on December…

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 a review of select facility policies and procedures, clinical record review, and family and staff interview, it was determined that the facility failed to obtain routine dental services for one of three residents reviewed for dental concerns (Resident 67). Findings include: The facility policy entitled, Dental Exams, last reviewed November 21, 2024, revealed that each resident will receive, at a minimum, an annual oral examination with a dentist or his/her choice. In addition to the minimum oral examination, each resident will be offered dental services every six months as his/her insurance will allow. Any resident or resident's responsible party may elect to have the annual oral examination done with the contract dentist. Interview with Resident 67's daughter on May 20, 2025, at 10:10 AM revealed that Resident 67 has natural teeth; however, Resident 67's daughter did not know the last time Resident 67 received professional dental services. Resident 67's daughter stated that she, .would love to see that happen. Clinical record review for Resident 67 revealed that 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 a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of six residents reviewed for infection control (Resident 83). Findings include: The policy entitled Standard Precautions and Transmission-Based Precautions, last reviewed without changes March 18, 2025, revealed the CDC recommends two tiers of precautions. In the first tier are those precautions designed for the care of all residents, regardless of their diagnosis or presumed infection status. Implementation of these standard precautions is the primary strategy for successful infection prevention and control. The second tier of precautions are designed only for the care of specified residents on a case-by-case basis. Airborne, Contact, and Droplet precautions are used for persons known or suspected to be infected or colonized with highly transmissible pathogens. These precautions will be instituted for any resident who has an active infection and/or requires more…

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 staff interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety and sanitation in the facility's main kitchen and three of seven nursing units (100, 300, 800). Findings include: An observation of the facility's main kitchen on June 17, 2024, at 8:30 AM revealed the following: The coffee beverage station lower shelf contained several dried brown liquid spills along with dust and debris. A white blanket was balled up in the back corner of the shelf along the wall with dried brown and orange stains on it. The tubing on several flavors of bag in box juice concentrates connecting them to the juice dispenser were sticky and covered in dust. The flooring under the steam table, serving area, fryer, and cooking equipment contained dried food and debris. The wall area beside the plate warmers was covered in dried food splatter. The lower shelves of two production tables had dust and debris. The sides and control panel area of the steam kettle were covered in dried liquid spills. The lower…

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, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 29 and 82). Findings include: The facility's medication error rate was 17.95 percent based on 37 medication opportunities with 7 medication errors. Observation of Employee 2, Licensed Practical Nurse (LPN), during a medication administration pass on June 17, 2024, at 8:32 AM revealed she poured and crushed both Metoprolol Tartrate (a medication used to treat high blood pressure) 12.5 milligrams (mg) by mouth and Potassium Chloride Extended Release (ER) 20 milliequivalent (mEq, a unit of measure used for electrolytes) one tab by mouth and attempted to administer them to Resident 29, who refused them. Observation of Employee 2 during a medication administration pass on June 18, 2024, at 8:48 AM revealed she poured and crushed Metoprolol Tartrate 25 mg, Paroxetine (a medication used to treat depression) 20 mg and Potassium Chloride ER and administered them 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 a review of facility policies and procedures and staff interview, it was determined that the facility failed to have a policy and procedure in place to address facility closure or termination of the facility's Medicare and/or Medicaid Provider Agreement. Findings include: During the entrance conference on June 17, 2024, at 8:35 AM the Nursing Home Administrator and Director of Nursing were asked to provide a copy of the facility's closure plan. The Director of Nursing revealed that the facility did not have a plan in the event of a facility closure. The Director of Nursing confirmed the facility was made aware of this during the previous full health survey in July of 2023. A follow-up interview with the Nursing Home Administrator on June 18, 2024, at 10:14 AM confirmed that the facility does not have a policy or procedure to address facility closure. 28 Pa Code 201.23 (c)(1) Closure of facility

Based on a review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure the administration of a COVID-19 immunization for four of five residents reviewed for immunization concerns (Residents 11, 109, 118, and 119). Findings include: The policy entitled COVID-19 Procedure for Testing, Quarantining, Source Control, and Vaccinations, last reviewed without changes on December 5, 2023, revealed the facility encourages everyone to remain up to date with all recommended COVID-19 vaccine doses. Residents, staff, and visitors will be offered COVID-19 vaccines through monthly booster clinics held at the facility. Clinical record review for Resident 119 revealed the facility admitted him on July 24, 2023. A review of Resident 119's immunization history information indicated that he received a COVID-19 immunization on March 4, 2021, April 1, 2021, and October 19, 2021. A review of facility documentation revealed that Resident 119's son gave permission on December 13, 2023, for the facility to…

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

Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure a resident was free from neglect resulting in injury for one of two residents reviewed (Resident 26). Findings include: Clinical record review for Resident 26 revealed a progress note dated May 24, 2024, at 6:00 AM that indicated she was being transferred in a mechanical lift when the top of the sling came loose, and she fell to the floor. She was noted to have bleeding from the back of her head. Assessment of her injuries indicated that she had a 2.5-centimeter (cm) x 0.3 cm laceration to the mid back of her head and a smaller laceration measuring 0.5 cm x 0.5 cm just above the other one. Review of the facility's investigation into Resident 26's fall revealed a statement from Employee 5, nurse aide, dated May 24, 2024, that indicated the lift slipped and Resident 26 slipped out of the sling onto the floor. Further review of the facility's investigation into Resident 26's fall revealed a statement dated May 24, 2024, at 9:00 AM from Employee 6,…

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 select facility policies, clinical record review, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of 27 residents reviewed (Residents 79). Findings include: The current facility policy entitled Abuse Prevention/Elder Justice Act Suspicious Crime Reporting, last reviewed without changes on December 5, 2023, revealed that all residents of the facility have the right to live without fear of abuse. The facility will ensure that all allegations of mistreatment, neglect, or abuse, as well as injuries of unknown source, are reported timely. The facility will prevent abuse and neglect through assessment and monitoring of residents, and educating employees, residents, and resident representatives. The facility will protect the rights of the residents, promptly report, and investigate incidents of alleged resident abuse, Clinical record review for Resident 79 revealed a care plan (a summary 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 clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for three of 27 residents reviewed (Residents 11, 116, and 119). Findings Include: Clinical record review for Resident 116 revealed that the facility admitted her on December 8, 2023, with a diagnosis of a prolapsed vaginal vault (the top of the vagina folds into the lower vagina) after a hysterectomy (a surgical procedure to remove the uterus). Clinical record review for Resident 116 revealed consultation reports dated March 13, 2024, and June 11, 2024, that indicated she was seen by a gynecology physician to have her pessary (a device that is inserted into the vagina to prevent or control a prolapse of the vaginal vault, bladder, or uterus) checked. Further clinical record review of Resident 116's care plan revealed the pessary was not noted on her plan of care. The Director of Nursing was made aware of the concern that there was no mention of Resident 116's pessary in her plan 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.

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 identify and assess a resident's decline in activities of daily living (ADL) for two of two residents reviewed for an ADL decline (Residents 10 and 118). Findings include: A review of Resident 10's MDS (Minimum Data Set, assessment completed at specific intervals to determine care needs) assessment dated [DATE], noted nursing staff assessed Resident 10 as requiring the supervision of one staff for bed mobility. Resident 10's next quarterly assessment dated [DATE], revealed nursing staff assessed Resident 10 as declining and now requiring extensive assistance of one staff for bed mobility. There was no documented evidence in Resident 10's clinical record to indicate that the facility identified or assessed Resident 10's decline in her ability to perform this activity of daily living. A review of Resident 118's MDS assessment dated [DATE], noted nursing staff assessed Resident 118 as independent with bed mobility. 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 clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights and feeding interventions for two of 27 residents (Residents 36 and 89). Findings include: Review of Resident 36's clinical documentation revealed the following physician orders: On January 17, 2024, and discontinued on March 1, 2024, staff were to complete a daily weight every day shift. Staff were to contact the physician if the weight increased by two-pounds in 24 hours or five-pounds in a week. On March 1, 2024, daily weights one time a day for CHF (Congestive Heart Failure, a heart condition that causes fluid build-up in the extremities and organs) for one week. On March 12, 2024, daily weights, make the physician aware if a two-pound weight gain in 24 hours or five pounds in one week, every day shift for CHF. Review of Resident 36's clinical documentation revealed no documented weights June 7, 2024. Further review of Resident 36's clinical documentation revealed that there was no physician notification…

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 interview, it was determined that the facility failed to ensure each resident's medication regimen was free of adverse medication reactions for one of five residents reviewed for unnecessary medications (Resident 50). Findings include: Clinical record review for Resident 50 revealed a pharmacy note to the physician dated March 12, 2024, informing the physician that the resident's concurrent use of the medications Omeprazole (a proton-pump inhibitor used to treat reflux disease) and Clopidogrel (a platelet inhibitor used to reduce the change of blood clot formation), may decrease the efficacy of the Clopidogrel, thus increasing the risk for clots. The pharmacist note questioned if the physician would like to switch the resident's proton pump inhibitor from Omeprazole to Pantoprazole (another proton pump inhibitor). Resident 50's physician responded to the pharmacist note on March 18, 2024, in agreement to change the resident's Omeprazole to Pantoprazole, and noted once the Pantoprazole arrives to discontinue the Omeprazole. Further review 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 clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 89). Findings include: Clinical record review for Resident 89 revealed a note to the attending physician/prescriber dated January 12, 2024, indicating that the following orders are due for a gradual dose reduction review, Buspirone (a medication used to treat anxiety) 5 milligrams (mg) in the morning and bedtime and 2.5 mg in the afternoon and Citalopram (a medication used to treat depression) 20 mg daily. Resident 89's physician checked the box on the form to indicate that she is benefitting from therapy without adverse effects and that the benefits of continued use outweigh risks. The prescriber did not indicate whether they agreed or disagreed to the recommendation or what benefit outweighed what the risk. Review of Resident 89's current physician orders revealed that there have been no changes to either of the medications. Interview with the Director…

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

Based on observation, review of a medication pass observation report, review of select facility policies and procedures, and staff interview, it was determined that the facility failed prevent the potential spread of infection during medication administration on 1 of 7 nursing units (600 hall, Resident 29). Findings include: The facility policy entitled, Specific Medication Administration Procedures Eye Drop Administration last reviewed on December 5, 2023, revealed the purpose was to administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner. Review of the medication pass observation report for Employee 2, Licensed Practical Nurse (LPN), dated April 30, 2024, revealed that for ophthalmic (eye) medications gloves should be worn and a separate tissue should be used for each eye. Observation of Employee 2 during a medication administration pass to Resident 29 on June 17, 2024, at 8:32 AM revealed she administered one drop of Systane eye drops (used to relieve and prevent dry eyes) to each eye. She held the eye drops in her ungloved hand and pulled…

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, review of facility documents, and staff interview, it was determined that the facility failed to thoroughly investigate and notify the appropriate agencies of an identified incident of potential resident misappropriation of property (medication) for two of five residents reviewed (Residents 4 and 5). Findings include: In an interview with Employee 1, licensed practical nurse (LPN), on June 5, 2024, at 9:33 AM she stated she was aware of a recent discrepancy with Resident 5's liquid morphine in which the color of the medication was a dark purplish color and was normally blue. Employee 1 indicated the bottle had been opened. In an interview with Employee 2, LPN, on June 5, 2024, at 9:38 AM she stated there was a recent report of Resident 5's opened bottle of liquid morphine being a different color than others on the unit, where it appeared a grayish/brown color instead of blue and the bottle was discarded. Employee 2 also indicated there had been prior recent discrepancies in the controlled substance count of doses remaining of liquid Morphine 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 a review of employee competencies and interviews with staff, it was determined that the facility failed to ensure that nursing staff completed competencies and skill sets necessary to care for residents' needs for three of nine employees (Employees 1, 2, and 3; Residents 1, 2, and 3). Findings include: Review of Resident 1's clinical record revealed that the facility admitted him on October 25, 2023, with orders for nursing staff to use and care for a Peripherally Inserted Central Catheter (PICC) line (a catheter inserted into the upper arm that goes into the larger central veins near the heart). Nursing documentation dated October 26, 2023, at 5:30 AM revealed that Employee 1, registered nurse, used Resident 1's PICC line to draw blood. Resident 1 indicated that his PICC line was never used to draw blood at the hospital. Nursing documentation dated October 26, 2023, at 9:21 PM revealed that Employee 2, registered nurse, changed Resident 1's PICC line dressing. Employee 2 documented that he changed the caps on the ends of the PICC lines. Nursing documentation dated October…

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.