San Rafael Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain clinical records that were accurately documented for 3 (Resident #1, Resident #2,and Resident #16) of 5 residents reviewed for medical records. 1. The facility failed to ensure Resident #1's vital signs were accurately documented in the MAR on 08/15/25.2. The facility failed to ensure Resident #2's blood pressure was accurately documented in the MAR during the month of September 2025.3. The facility failed to ensure Resident #16's blood pressure was accurately documented for the month of September 2025. These failures could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings included:1. Record review of Resident #1's face sheet dated 09/25/25 reflected a [AGE] year-old male with an original admission date of 11/03/23. Diagnoses included end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), hypertension (high blood…

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, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one resident (Resident #5) of three residents reviewed for skin irregularities. When Resident #5 was readmitted into the facility on [DATE], LVN E failed to complete a thorough and accurate head-to-toe assessment that included assessing what was under Resident #5's right arm dressing/bandage. This failure could compromise a resident's skin integrity, which could increase the risk for progressive skin complications. Record review of the Resident #5's admission Record dated 10/24/2025 revealed Resident # 5 was a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. Resident #5 was admitted with multiple diagnoses which included: cerebral infarction (stroke), muscle wasting and atrophy, intellectual disabilities, hemiplegia (paralysis of a limb) 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 observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 1 of 2 wound treatment carts on hall 100 reviewed for storage.The 100 hall wound care treatment cart was found unlocked.This failure could place residents at risk of access and ingestion of medications or supplies not intended for them and/or misappropriation. Findings were:Observation on 10/21/2025, at 11:24 a.m., a wound care treatment cart was found unlocked in front of the 100 hall nursing station. The observation of items inside the wound care cart included: betadine solution, hydrogen peroxide, triple antibiotic ointment, nystatin cream, diclofenac sodium gel, iodoform packing strips, lidocaine cream, and a variety of bandages used for wound care treatment.During an interview on 10/21/2025 at 11:30 a.m., LVN A verbalized the treatment cart was an extra cart and was not assigned to any staff member. LVN A verbalized she was unsure who used the cart…

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 interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #5) of three residents reviewed for total body skin assessment documentation. 1. When Resident #5 was readmitted into the facility on [DATE], LVN E failed to document a bandage on Resident #5's forearm/elbow area. 2. When Resident #5's skin irregularity was assessed on 09/25/2025, LVN F failed to document and detail the right arm skin impairment. These failures could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs. Record review of the Resident #5's admission Record dated 10/24/2025 revealed Resident # 5 was a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. Resident #5 was admitted with multiple diagnoses which included: cerebral infarction (stroke), muscle wasting 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 interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the appropriate State Agency, but no later than 2 hours after the allegation was made, for 1 of 5 Residents (Resident #1) reviewed for reporting allegations of abuse and/or neglect. The facility failed to report Resident #1's fall with a major injury on 06/01/25 in which Resident #1 sustained a left hip fracture. State Agency was not notified of the fall with injury. This failure could result in placing residents at increased risk for not receiving a proper or thorough investigation. The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip fracture which occurs in the upper part of the femur which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, and if the alleged violation was verified appropriate, corrective action must have been taken for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and/or misappropriation. The facility failed to do a thorough investigation to include interviewing Resident #1, as well as other residents or staff which may have been involved in or witnessed the incident. This failure placed residents at risk of not having their allegations investigated thoroughly or timely. The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip…

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, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 2 of 2 nutrition rooms for storage, preparation, and sanitation. The facility failed to use internal thermometers in 2 freezers. The facility failed to maintain cleanliness of shelves, the ice machine, coffee cups, and microwave oven throughout the kitchen. The facility failed to follow a proper cleaning schedule. The facility failed to ensure kitchen utensils were in good working order. The facility failed to ensure dented holding pans were not in use and on the clean rack. The facility failed to ensure the dumpster side doors were kept closed. The facility failed to ensure all containers of food in the refrigerator was labeled. The facility failed to ensure boxes of food were not stacked too close to the ceiling in the walk-in refrigerator. The facility failed to ensure personal items were not on the shelves with dry storage items and canned goods. The facility failed…

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, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Observation and initial tour of the kitchen with the DM on 03/04/25 at 8:35 am revealed there were roaches in the upper mechanical part of the ice machine. She opened the upper part of the ice machine, and a roach ran across the opening, then several more roaches emerged from under the front edging. She said the roaches could carry diseases and could make the residents sick. In an interview with the DM on 03/04/25 at 8:45 am, she said the process for reporting equipment that needed to be repaired or replaced was for her to place the request in the facility's electronic reporting system, the MS received a text, and all requests were discussed in the daily morning meetings. Observation and re-visit to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 8 (Resident #75 and Resident #110) residents reviewed for accurate procedures for medication administration. 1a. The facility failed to ensure LVN C checked and/or documented an accurate blood pressure for Resident #75 before administering Resident #75's blood pressure decreasing medication that had physician ordered hold parameters on 5 of 12 opportunities from 02/01/25 to 03/04/25. 1b. The facility failed to ensure LVN I checked and/or documented an accurate blood pressure for Resident #75 before administering Resident #75's blood pressure decreasing medication that had physician ordered hold parameters on 10 of 11 opportunities from 02/01/25 to 03/04/25. 2a. The facility failed to ensure LVN E checked and/or documented an accurate…

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, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 5 (Resident #16, Resident #34, Resident #75, Resident #83, Resident #88) of 8 residents reviewed for infection control. 1. The facility failed to ensure LVN C sanitized the blood pressure cuff between use on Resident #83, Resident #88, Resident #34, Resident #75, and Resident #16 on 03/06/25. These failures could place the residents at risk of cross-contamination and development or spread of infection. Findings included: 1. Record review of Resident #83's admission record reflected a [AGE] year-old male that was admitted to the facility on [DATE] with an original admission date of 01/19/23. Resident #83's diagnoses included unspecified meningitis (inflammation of the tissues surrounding the brain and spinal cord usually caused…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge, and the reasons for the transfer or discharge, in writing to the resident, resident representative, or the Office of the State Long-Term Care Ombudsman as soon as practicable before transfer or discharge when an immediate transfer or discharge was required for urgent medical needs for 2 of 5 residents (Resident #24 and Resident #66) reviewed for transfer and/or discharge. The facility failed to send written notice of transfer or discharge of Resident #24 ' s transfer on 01/28/25, and Resident #66 ' s transfer on 01/25/25. This failure could affect residents by placing them at risk of being discharged and not having access to available resources, advocacy services, discharge/transfer options, and the appeal processes. Findings included: 1.Record review of Resident #24 ' s face sheet dated 03/06/25 revealed a [AGE] year-old female with an original admission date of 02/15/19, and a current admission date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #43) of 5 residents reviewed for comprehensive person-centered care plans. The facility failed to develop and implement Resident #43 ' s care plan to include oxygen therapy. This failure could affect the resident by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The findings included: In an observation on 03/04/2025 at 11:00 AM of Resident #43, revealed he did not have any oxygen on, and there was no oxygen concentrator, tubing or other equipment in his room. Record…

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, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received assistance devices to prevent accidents for one of five residents (Resident #103) reviewed for accidents and hazards. The facility failed to ensure floor mats were in place beside Resident #103 ' s right side of the bed. This failure could place residents at risk for an injury or a major injury. The findings include: Record review of Resident #103 face sheet, dated 03/05/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #103 had a diagnosis which included Benign Paroxysmal Vertigo (a feeling of spinning), Unspecified Ear. Record review of Resident #103's Significant Change Minimum Data Set assessment dated [DATE] indicated she had Cerebrovascular accident (stroke), muscle wasting and other lack of coordination. The assessment indicated Resident #103's brief interview of mental status…

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, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #7) residents reviewed for respiratory care. The facility failed to ensure Resident #7's oxygen concentrator administered oxygen at the correct setting of 2 liters per minute. Resident #7's oxygen concentrator was set at 3 liters per minute on 03/04/2025 at 8:33 AM and at 4:55 PM. This failure places residents who receive respiratory care at an increased risk of developing respiratory complications, and a decreased quality of care. The findings included: Resident #7's face sheet dated 03/04/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had a diagnosis which included Chronic Obstructive Pulmonary disease (a common lung disease causing restrictive…

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, the facility failed to dispose of expired biologicals in 2 of 2 medication rooms reviewed for storage. The facility failed to discard 19 expired swab kits in the 100-hall medication room. The facility failed to discard an expired enteral feeding tube de-clogger device in the 200-hall medication room. These failures could place residents at risk of infection and diminished quality of life. Findings included: Observation of the 100 hall medication room on [DATE] at 8:32 AM revealed expired medication and specimen swabs: 1 glucagon pen (emergency use for low blood sugar) expired [DATE]. 1 urine-vaginal-STI (sexual transmitted infection) expired [DATE]. 1 wound swab kit expired [DATE]. 4 buccal (mouth) swab kits expired [DATE]. 2 vaginal swab kits expired [DATE]. 3 vaginal swab kits expired [DATE]. 7 wound/tissue swab kits expired [DATE]. Observation of the 200 hall medication room on [DATE] at 8:37 AM revealed 1 enteral feeding tube de-clogger expired [DATE]. In an interview…

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, the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 5 (RD) qualified dietary staff reviewed. The facility failed to ensure the registered dietician (RD) attended weekly weight meetings. This failure could affect residents who ate food from the kitchen and could result in the dietary needs of residents not being met. The findings included: In an interview with the ADON F on 03/06/25 at 1:52 pm, she said the RD was supposed to visit the facility weekly for weekly weight meetings but came in primarily for monthly meetings. She said the monthly meetings included the RD, ADONs, DM, wound care nurse, the DOR, and the DON. She said the RD did not call in to attend the weekly meetings. She said the RD would often miss meetings. She said dietary was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 8 residents (R #75) reviewed for accuracy of records. -The facility failed to ensure LVN C checked and/or documented an accurate blood pressure for Resident #75 before administering Resident #75's blood pressure decreasing medication that had physician ordered hold parameters on 5 of 12 opportunities from 02/01/25 to 03/04/25. -The facility failed to ensure LVN I checked and/or documented an accurate blood pressure for Resident #75 before administering Resident #75's blood pressure decreasing medication that had physician ordered hold parameters on 10 of 11 opportunities from 02/01/25 to 03/04/25. -The facility failed to ensure LVN I did not document a blood pressure reading for Resident #75 when he was not given his blood pressure medication due to being out of the facility on 2 of 2 opportunities 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, the facility failed to provide a safe, clean, and sanitary environment for 1 of 1 kitchen. The facility failed to maintain an electrical outlet, lighting fixture, and two AC ducts from dripping water and water damage in the kitchen. These failures could place residents at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment. The findings included: Observation and initial tour of the kitchen on 03/04/25 at 8:35 am revealed there was an electrical conduit box and a lighting fixture in the ceiling above the stove that were dripping water. The nearby AC return was dripping water. Observation and re-visit to the kitchen on 03/05/25 at 9:15 am revealed the AC return on the ceiling of the DM's office appeared to have water damage to the sheetrock around the frame, which was swollen and gaping open. In an interview and observation with the MS on 03/04/25 at 8:55 am, he said the leak around the electrical conduit, AC return, and lighting fixture had been dripping condensation…

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 the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 3 of 5 residents (Resident #3, Resident #4, and Resident #5) reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure administration of narcotic medication was accurately documented in the electronic medication administration record when Resident #3 received Lorazepam (a controlled medication [benzodiazepine] used to relieve symptoms of anxiety) 9 times between 01/10/25 and 01/13/25. 2. The facility failed to ensure administration of narcotic medication was accurately documented in the electronic medication administration record when Resident #3 received Tramadol (a schedule IV controlled opioid medication used to treat pain) 2 times between 01/10/25 and 01/11/25. 3. The facility failed to ensure administration of narcotic medication was accurately…

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 the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of five residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. On 09/28/24, Resident #2 pushed Resident #1 backward. Resident #1 tripped, then fell and hit the back of her head on the floor which resulted in a hematoma (swelling) to the back of her head. This failure could place residents at risk for abuse and physical, mental, and psychosocial harm. The findings included: 1. Record review of Resident #1's admission record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (several diseases that affect memory, thinking, and the ability to perform daily activities, Alzheimer's (a progressive disease that destroys memory and other important mental functions), blindness left eye, muscle…

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 the facility failed to ensure each resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 1 of 6 residents (Resident #3) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #3's lorazepam (a controlled medication [benzodiazepine] used to relieve symptoms of anxiety) and Tramadol (a schedule IV controlled opioid medication used to treat pain) tablets. This failure could place residents at risk for not receiving prescribed medications which could lead to physical, mental, or psychosocial harm. The findings included: Record review of Resident #3's admission record reflected an [AGE] year-old female, who was admitted to the facility on [DATE]. She had diagnosed which included dementia (the loss of cognitive functioning), anxiety disorder (a mental health disorder characterized by feelings of worry, fear, or nervousness that are strong enough to interfere with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 5 resident's (Residents #1) reviewed for accidents/supervision in that: CNA B failed to have a second staff assist her with care for Resident #1 and Resident was left unattended and rolled off her bed during incontinent care on 06/12/24. This failure could place residents at risk for injuries related to falls. The findings were: Record review of Resident #1's Face Sheet dated 06/16/21 documented a [AGE] year-old female with diagnoses including Cerebral Palsy (abnormal brain development that affect's a person's ability to control their muscles), muscle wasting, Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), seizures, Alzheimer's, heart failure, and mild intellectual disabilities. She was her own self representative. Record review of Resident #1'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 the facility failed to ensure that drugs and biologicals were stored behind a closed and locked door in a secured unit (Hall 300) in one of 3 medication rooms. The medication door was left open on hall 300.This failure could place residents at risk of access and ingestion of medication in the medication room. Findings were: Observation on 1/8/2025, at 4:23 p.m., revealed the medication room door was open and unlocked. The medication door was unlocked for 5 minutes until LVN A exited a room and returned to the nurses station (medication room door located inside of nurses ' station). The refrigerator door was locked, and the discontinued tub of medications were locked. No medication was immediately accessible including over the counter medications without a key to the refrigerator and the tub of medications. During an interview on 1/8/2025 at 4:28 p.m., LVN A verbalized she was in a room helping a resident with sit to stand equipment. She verbalized she thought she shut and locked the door of the medication room before leaving the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one of one residents reviewed for call lights. The facility did not ensure Resident #1's call light was with in reach. This failure could place residents at risk for illness due to cross contamination in the kitchen and left a resident without access to staff and at risk for falling. Findings included: Record review of a face sheet dated 9/4/2024 indicated Resident #1 was a [AGE] year old who was admitted on [DATE] with diagnoses of Hemiplegia and hemiparesis of the left side following a cerebral infarction affecting the left non-dominant side (a stroke causing weakness or total paralysis of the left side of the body), Vascular Dementia (a progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), lack of coordination, and abnormalities of gait and ambulation (walking). Review of a quarterly MDS assessment…

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

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one kitchens reviewed for safety. The kitchen vent was drpiping condensation from the ceiling to the surface beneath the area creating slipping hazards and possible contamination during food prepartation. This failure could place residents at risk for illness due to cross contamination in the kitchen and left a resident without access to staff and at risk for falling. Findings included: Observation and interview on 9/4/2024 at 11:51 am, revealed the kitchen area the ceiling ventilation was dripping onto the floor space very near a table. During the interview of the Kitchen Manager, she stated I didn't notice it was dripping, but there is no cross contamination due to the water not being directly over the food preparation area. The Kitchen Manager also stated, all residents are served out of the kitchen except one resident that has a feeding tube. During an interview with the Maintenance Director on 9/5/2024 at 3:00 pm, he stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 Residents (Resident #1) reviewed for medical records accuracy, in that: Resident #1's clinical record was incomplete. Staff did not document Residents #1's fall that occurred on 06/21/24 in the shower room. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: Record review of Resident #1's face sheet, dated 06/30/24, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia (paralysis to one side of body) and hemiparesis (weakness to one side of body) following cerebral infarction (ischemic stroke -occurs when the blood flow to brain is disrupted) affecting left dominant side. Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one facility reviewed for environment. 1. The facility failed to ensure resident rooms were safe and in good repair 2. The facility failed to ensure the smoking area had self-closing lids for discarded cigarette butts 3. The facility failed to ensure the maintenance log work orders were fulfilled before signing off 4. The facility failed to ensure resident closet ceilings and hallways were safe and in good repair These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Observations of the facility and hall 300 (locked unit) beginning on 06/04/24 at 10:00 am revealed the side lobby, employee restroom, and the 300 Hall including the activity area, rooms 304-316 revealed what appeared to be water damage in almost every resident's closet near the baseboards, as the sheetrock was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 residents (Resident #1) of 1 resident reviewed for abuse/neglect. The facility did not report the allegation of resident neglect to the State Survey Agency within the allotted time frame for Resident #1 who had eloped from the facility on 12/18/2023. This failure could place all residents at risk for injuries, abuse, and/or neglect due to not reporting or completing investigations of elopements. Findings included : Record review of Resident #1's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease (brain condition that…

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, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure dishes were clean and sanitized 2. The facility failed to ensure equipment was clean and sanitized 3. The facility failed to ensure food in the freezer was properly contained 4. The facility failed to ensure dry storage items and spices were sealed properly 5. The facility failed to maintain cleanliness of the floor in the kitchen 6. The facility failed to properly label and date items in the refrigerator These failures could place residents at risk of foodborne illnesses. Findings include: Observation of the kitchen beginning 12/11/23 at 10:20 a.m. revealed 17 of 36 plastic bowls, 14 of 25 plastic coffee cups, and 10 of 10 plastic drinking glasses had a whitish residue in them, some heavier than others. The ice machine had a removable dark…

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, interviews, and record reviews, the facility failed to maintain all equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: 1. Bowls, cups, and glasses had whitish residue in them 2. The vent hood manifolds were rusted 3. Two freezers were inoperable These failures could place residents and staff at risk of foodborne illnesses and injury. Findings included: Observation of the kitchen beginning 12/11/23 at 10:20 a.m. revealed 17 of 36 plastic bowls, 14 of 25 plastic coffee cups, and 10 of 10 plastic drinking glasses with a whitish residue in them, some heavier than others. The vent hood manifolds were badly rusted. Two large freezers were unplugged and not operating. Both of the freezers were warm inside and had an odor. Interview with the CFM on 12/11/23 at 10:25 a.m. during the initial tour of the kitchen stated parts had been ordered for the freezers and she had invoices for them. The CFM stated one of the freezers went out a month ago and the other one, 2 weeks later, and she took them both out of service, leaving two…

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, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 4 residents Resident # 83 (R#83), Resident #35 (R#35), Resident #414 (R#414 ), Resident #49 (R#49) of 10 residents reviewed for accommodation of needs. The facility staff did not provide R#83, R#35, R#414, R#49 with a call light that was within reach. This failure could place residents who utilized call lights at risk for not having their needs met. Findings included: R #83: Review of R #83's Face Sheet dated 12/14/23 documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Cerebral Palsy, Unspecified and Chronic Kidney Disease, Unspecified. Review of R #83's Quarterly Minimum Data Set assessment dated [DATE] revealed R #83: -required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene -had impairment on both sides of lower extremity (hip, knee,…

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, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 33 residents (Residents 57 (room [ROOM NUMBER]), 109 (room [ROOM NUMBER]), 24 (room [ROOM NUMBER]), 88 (room [ROOM NUMBER]), 15 (room [ROOM NUMBER]), 64 (room [ROOM NUMBER]), 103 (room [ROOM NUMBER]), 6 (room [ROOM NUMBER]), 19 (room [ROOM NUMBER]), 26 (room [ROOM NUMBER]), 16 (room [ROOM NUMBER]), 25 (room [ROOM NUMBER]), 106(room [ROOM NUMBER]), 56 (room [ROOM NUMBER]), 41 (room [ROOM NUMBER]), 27 (room [ROOM NUMBER]), 52 (room [ROOM NUMBER]), 21 (room [ROOM NUMBER]), 230 (room [ROOM NUMBER]), 40 (room [ROOM NUMBER]), 60 (room [ROOM NUMBER]), 73 (room [ROOM NUMBER]), 82 (room [ROOM NUMBER]), 37 (room [ROOM NUMBER]), 34 (room [ROOM NUMBER]), 8 (room [ROOM NUMBER]), 32 (room [ROOM NUMBER]), 55 (room [ROOM NUMBER]), 39 (room [ROOM NUMBER]), 51 (room [ROOM NUMBER]), 99 (room [ROOM NUMBER]), 107(room [ROOM NUMBER]) and 102(room [ROOM NUMBER]) of 41 residents residing 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, record review, and interview, the facility failed to ensure the resident environment was as free of accident hazards as is possible, on the 100 hall, for 1 of 3 shower rooms observed for hazards. The facility failed to secure the shower room door and securely store chemicals to keep out of reach from any resident that resided within the first-floor unit. These failures could place residents at risk for accidental poisonous hazards. The finding include: During an observation on 12/12/2023 at 8:34AM, Observed a 100 hall shower room and door slightly opened, and upon further inspection on the left side of the slightly opened door, observed a sign that stated shower room. Through the door opening a visible red/white tubing was observed. To proceed with further inspection, this surveyor retrieved ADON and inquired if the door was opened, to which he responded by physically pushing the entry shower room door. On a shelf to the left of the room, was a red/white tube with a label of All-purpose Caulk: Use on tubs, sinks, windows, trim and more. Warning! May cause 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 25 opportunities which resulted in an 8 percent error rate involving Resident #1. 1. LVN A administered another resident's IV Vancomycin 1gram/250mL normal saline to Resident #1. The name on the Vancomycin IV medication bulb label had another person's name the label which was not Resident #1's name. 2. CMA A did not follow the physician's order to hold medication if the blood pressure was less than 110/60 mmHg. Resident #1's blood pressure was 107/77 mmHg, and CMA A administered Resident #1's Metoprolol Tartrate 25mg tablet. These failures could affect residents that are sensitive to cardiac medication which could lower blood pressure which could lead to life-threatening outcomes, as well as affect residents who are not on Vancomycin by damaging their kidney function. Findings Included: Record review of Resident #1's face sheet, dated 12/11/2023, revealed…

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, the facility failed to ensure that 1 (Resident #1) of 7 residents reviewed for significant medication errors, was administered his medication as per his physician's order. The facility did not carry out Physician's Orders to hold Resident#1's Metoprolol Tartrate 25mg tablet for blood pressure less than 110/60mmHg. This failure could affect multiple residents who reside in the facility who are taking blood pressure medication by causing a decline in their quality of care and quality of life due to not only the lack of competent blood pressure monitoring but also the lack of adherence to physician's orders. The findings were : Record review of Resident #1's face sheet, dated 12/11/2023, revealed she was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bone infection), sepsis (infection), and methicillin resistant staphylococcus aureus infection. Record review of Resident #1's MDS assessment dated [DATE] documented Resident #1: -had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the wound care nurse (LVN B) had the specific competencies and skills sets necessary to care for 1 of 5 residents (Resident #101) that required wound care. 1.LVN B did not provide wound care for Resident #101 for 2 days but documented wound was provided.Resident #101's physician orders stated wound care be performed every day and as needed. This deficient practice could place residents requiring wound care at risk for adverse effects and have the potential to result in the development of infection, sepsis, and pain. The Findings: Review of the clinical record for Resident #101 reflected a [AGE] year-old female with an admission original date of 6/28/2023 and a readmission dated of 11/8/2023. Diagnoses included, type 2 diabetes (insufficient production of insulin in the body), end stage renal (kidney) disease, hypertension (high blood pressure), surgical aftercare following surgery on the skin and subcutaneous tissue, skin graft…

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, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for one Resident (R #1) of six residents reviewed for care plans, in that: The facility failed to update R #1's care plan to include history of fabricating stories, as well as failed to update R#1's care plan to reflect actual event that transpired on 11/12/2023. This failure could place residents at risk for not having their needs met and psychosocial complications. The findings included: Record review of R #1's Face Sheet dated 11/26/2023 documented an [AGE] year-old male initially admitted [DATE] and re-admitted [DATE] with the diagnoses of: cerebral infarction, dementia, encephalopathy, and abnormalities of gait and mobility. Record review of R #1's Minimum Data Set, dated [DATE] documented R #1: -BIMS score 07 out of 15 revealing…

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 the facility failed to ensure that one resident with an indwelling urinary catheter received appropriate treatment and services for one (Resident #1) of three residents reviewed for urinary catheters, in that: CNA A did not ensure Resident #1's indwelling catheter tubing was allowed to flow freely via gravity drainage. Resident #1's catheter bag was incorrectly positioned on top of the resident's bed, which was situated above the resident's bladder for an undetermined amount of time, during the entire duration of cleaning care. These failures could place residents with indwelling urinary catheters at risk of infection. The findings include: Record review of Resident #1's Face Sheet dated 10/06/2023, documented a [AGE] year-old male initially admitted [DATE], with readmission date 09/22/2023, with the diagnoses of: Cerebral palsy (disorder that affect a person's ability to move and maintain balance and posture), Neurocognitive disorder (damage of the brain),…

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 the facility failed to ensure adequate supervision and services were provided to prevent accident hazards for 1 of 5 resident reviewed for accidents, Resident #1 (R #1) in that: The facility failed to recognize a trapeze bar hanging above resident's bed installed by a family member without consent from facility. The device was attached to the resident's bed overnight from 6/23/23 until morning of 6/24/23. The trapeze equipment fell onto R #1 when he was adjusting himself in bed which resulted in R #1 sustaining a serious injury of a left tibia and fibula fracture and concussion. This failure of identifying and preventing the installment and use of unapproved medical equipment could lead serious injury. The findings included: Record review of R#1 clinical file revealed a [AGE] year-old male, with an original admission date of 1/17/2023. Diagnosis included Paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), Fracture 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 observation, interview, and record review the facility failed to ensure all essential equipment is maintained in safe operating condition for 1 (Resident #1/R #1) of 5 residents reviewed for maintenance of medical equipment, in that: The facility failed to recognize a trapeze bar hanging above resident's bed installed by family member without consent from facility. The device was attached to the resident's bed overnight from 6/23/23 until morning of 6/24/23. The trapeze equipment fell onto R #1 when he was adjusting himself in bed which resulted in R #1 sustaining a serious injury of a left tibia and fibula fracture and concussion. This failure of identifying and preventing the installment and maintenance of unapproved medical equipment could lead serious injury for residents requiring medical equipment. The findings included: Record review of R#1 clinical file revealed a [AGE] year-old male, with an original admission date of 1/17/2023. Diagnosis included Paraplegia (paralysis of the legs and 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.