Lakeside Health and Wellness

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 5 residents (Resident #3 and Resident #68) reviewed for accuracy of MDS assessments. 1) The facility failed to ensure Resident #3's MDS accurately reflected the resident was PASRR positive for mental illness. 2) The facility failed to ensure Resident's #68's MDS accurately reflected PASRR positive for mental illness.These failures could place residents at risk of not receiving the necessary care and services to prevent falls and injuries related to inaccurate MDS assessments. Findings included: 1. Record review of Resident #3's face sheet, dated 1/22/26, indicated reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had with the diagnoses which included PTSD (post-traumatic stress disorder), depression (a mood disorder that cause a persistent feeling of sadness and loss of interest), and anxiety (persistent, excessive worry 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 interview and record review, the facility failed to ensure assessments were coordinated with Preadmission Screening and Resident Review (PASRR) program under Medicated in subpart C to the maximum extent practicable to avoid duplicative testing and effort and coordination included incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 8 residents (Resident #41) reviewed for PASRR.The facility did not ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Resident #41 who had a diagnosis of mental illness upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance…

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 residents received proper treatment devices to maintain vision and hearing abilities, and if necessary, assisted the residents in making appointments for 1 of 2 residents (Resident #61) reviewed for hearing devices. The facility did not ensure an appointment for an audiologist (healthcare professional specialized in hearing) for Resident #61 after she reported missing hearing aids. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation. Findings include: Record review of Resident #61's face sheet, dated 12/30/26, reflected Resident #61 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #61's quarterly MDS assessment, dated 12/30/25, reflected Resident #61 made herself…

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 a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences for 1 of 2 residents (Resident #41) reviewed for oxygen therapy. The facility failed to ensure Resident #41's oxygen concentrator filter was cleaned. This failure could place residents at risk for developing respiratory complications and a decreased quality of care.Findings include: Record review of Resident #41's face sheet, dated 01/22/26, reflected Resident #41 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #41's comprehensive care plan, revised 08/01/23, reflected Resident #41 had COPD. The care plan interventions included: oxygen therapy per MD order.…

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 act upon the recommendations of the pharmacist report of irregularities for 1 of 24 residents (Resident #41) reviewed for (DRR) Drug Regimen Review. The facility failed to timely implement Resident #41's signed Pharmacist Recommendation to Physician on 05/08/2025, which agreed with the pharmacy recommendation to discontinue Mag-Oxide 400 mg QAM (supplement). This failure could place residents at risk for receiving unnecessary medications at the most effective dosage.Findings included: Record review of Resident #41's face sheet, dated 01/22/26, reflected Resident #41 was a [AGE] year-old female, admitted [DATE] with diagnosis of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the order summary report, dated 01/22/26, reflected an active physician's order for: Mag-Oxide 400 mg; 1 tablet by mouth one time a day for supplement with a start date of 05/02/24. Record review of Resident #41's annual MDS…

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

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 4 medication carts (200 hall Nurse Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure one vial of albuterol sulfate 2.5 mg/3ml (medication used for breathing treatments) and a tube of diclofenac topical gel 1% (medicated gel applied on the skin to decrease pain/inflammation) were stored properly, when they were left on top of the 200 hall Nurse Medication Cart unattended on 01/21/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: During an observation and interview on 01/21/2026 starting at 4:57 PM, one vial of albuterol sulfate 2.5 mg/3ml and a tube of diclofenac topical gel 1% were on top of the 200-hall Nurse Medication Cart, unattended, on the 200 hall. Multiple staff and residents were observed in the hallway around 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 interviews and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs for 1 of 2 (Resident #61) residents reviewed for dental services. The facility did not ensure Resident #61 was provided with routine dental services related to dentures in a timely manner. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Record review of Resident #61's face sheet, dated 12/30/26, reflected Resident #61 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #61's order summary report, dated 01/22/26 reflected an active physician order for PRN dental care with an order date of 08/19/24. Record review of Resident #61's quarterly MDS assessment, dated 12/30/25, reflected Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 2 of 4 residents reviewed for personal food safety. (Residents #3 and Resident #52)The facility failed to ensure Residents #3's and Residents #52's personal refrigerator temperature logs were properly checked and documented. This failure could place the residents at risk for food borne illnesses.Findings included: 1.Record review of Resident #3's face sheet, dated 1/22/26, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included PTSD (post-traumatic stress disorder), depression (a mood disorder that caused a persistent feeling of sadness and loss of interest), and anxiety (persistent, excessive worry that interferes with daily life). Record review of Resident #3's admission MDS assessment, dated 12/11/25, indicated she made herself understood and she understood others. The MDS also indicated a BIMS score of 12, which indicated…

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 interviews and record review the facility failed to protect the resident's right to be free from verbal abuse for 1 of 4 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident #1 was free from abuse when CNA D was observed standing over resident, loudly talking and telling Resident #1 you tripping in response to resident's statements on 03/01/2025.This failure could place residents at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, impaired quality of life and abuse. Findings Included: Record review of Resident #1's admission Record dated 11/18/2025 revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses to include cerebral infarction (a restriction of blood supply to tissues caused by a blockage that stops blood flow to part of the brain), ataxia (a neurological symptom characterized by lack of muscle coordination), bilateral osteoporosis (a disease that causes bones to become weak and brittle),…

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 residents had the right to be free from misappropriation of property and exploitation for 1 of 4 residents (Resident #2) reviewed for misappropriation and exploitation, in that:The facility failed to ensure that Resident #2 was not subject to financial misappropriation or exploitation from CNA C. CNA C purchased personal items with the monies of Resident #2 in the amount of $230.83 during an outing to a local store without the permission of Resident #2. This failure had the potential to affect the residents in the facility by placing them at risk for decreased quality of life, feelings of loss and misappropriation of property. Findings Included: Review of Resident #2's admission Record, dated 11/18/2025, reflected a [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses to include spinal stenosis (the narrowing of the spinal canal, which can put pressure on the spinal cord and nerves), spondylosis (a degenerative condition 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 review and revise Resident Care Plans after each assessment for 1 of 4 Residents (Resident #3) whose records were reviewed for care plan revision/timing, in that: The care plan of Residents #3 was not updated to reflect a pureed diet. This deficient practice could affect any resident and contribute to residents not receiving the care and services they need.The findings included:Record review of Resident #3's admission Record, dated 11/18/2025, revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses to include dementia (a decline in mental ability that affects memory, thinking, and daily function), dysphagia (swallowing difficulty), Chronic Obstructive Pulmonary Disease (a progressive group of lung diseases that make it difficult to breathe), Peripheral Vascular disease (a circulation disorder affecting the arteries and veins outside of the heart caused by blockage from plaque buildup), Obstructive Uropathy (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 observations, interviews, and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for one (Resident #4) of four residents reviewed for physician orders for treatments. The facility failed to follow physician orders and remove Resident #4's staples to back of head on 11/13/25, five days after insertion during an ER visit on 11/8/25 per physicians' orders. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings Included:Record review of Resident #4's admission Record, dated 11/18/2025, reflected an [AGE] year-old male admitted on [DATE] with diagnoses to include Congestive Heart Failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs, causing blood and fluid to back up in other organs), Hypertension (high…

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 requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 6 residents reviewed for respiratory care (Resident #6). The facility failed to ensure Resident #6's oxygen tubing and water were changed out and dated. The facility failed to ensure Resident #6 had an order for her oxygen. The facility failed to have an order in place to ensure Resident #6's oxygen tubing and water were changed and dated, and the filter cleaning was completed weekly on Sundays. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: Record review of Resident #6's face sheet dated 11/18/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses chronic obstructive pulmonary disease (progressive lung condition that causes difficulty breathing…

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 establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 3 residents (Resident #8, Resident #22, and Resident #15) reviewed for pharmacy services. The facility failed to ensure MA V accurately reconciled Resident #8's narcotic medication log when she administered Resident #8's morphine (controlled medication used for pain) tablet on 10/15/24. The facility failed to ensure MA V accurately reconciled Resident #22's narcotic medication log when she administered Resident 22's pregabalin (controlled medication used to treat pain caused by nerve damage) tablet on 10/15/24. The facility failed to ensure LVN W accurately reconciled Resident #15's narcotic medication log when she administered Resident #15's Norco (controlled medication used…

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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 18.75%, based on 12 errors out of 64 opportunities, which involved 2 of 7 residents (Resident #18 and Resident #57) reviewed for medication administration. The facility failed to ensure LVN W administered Resident #57's scheduled morning medications as prescribed on 10/15/24. The facility failed to ensure MA X administered Resident #18's multivitamin with minerals and Reglan as prescribed on 10/15/24. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #57's face sheet dated 10/17/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to 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.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 23 residents (Resident's #6, #14, and #39) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #6, Resident #14, and Resident #39, who complained the food was served cold, was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: During an interview on 10/14/2024 at 3:03 p.m., Resident #14 stated the food was okay, but it was too cold most of the time. During an interview on 10/14/2024 at 3:25 p.m., Resident #6 stated the food had no taste and was overcooked most of the time. During an interview on 10/14/2024 at 3:36 p.m., Resident #39 stated the food was not good, very bland. During an observation and interview on 10/15/2024 at 1:03 p.m., a lunch tray was sampled by [NAME] U and four surveyors. The…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure hair restraints were worn appropriately by dietary staff. 2. The facility failed to ensure the dishwasher was in correct temperature range of 120 during wash cycle. 3. The facility failed to ensure chemical test strips were used for dishwasher. These failures could place residents at risk for foodborne illness. Findings include: During an observation in the kitchen on 10/14/2024 at 10:20 a.m., revealed [NAME] U was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] U's hair was visible outside of the hairnet in the back approximately four inches. During an observation in the kitchen on 10/14/2024 at 10:28 a.m., revealed dietary aide S was not wearing a hair restraint appropriately while preparing the lunch meal. Dietary aide S's hair was visible outside of the hairnet in the back approximately three to four inches.…

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 and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #43 and Resident #176) and 2 of 4 clean linen carts (Hall 300 and Hall 400 clean linen carts) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure the MDS Coordinator applied PPE prior to flushing Resident #176's PICC line on 10/16/2024 2. The facility failed to ensure CNA M changed her gloves and performed hand hygiene and did not touch the wipes container with dirty gloves while providing incontinent care to Resident #43 on 10/14/2024. 3. The facility failed to ensure Hospice Aide L did not carry unbagged, dirty linen in her hand down the hall on 10/16/2024. 4. The facility failed to ensure CNA K did not leave a bag with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 2 of 23 residents reviewed for advanced directives. (Residents #66 and #225) 1. The facility failed to ensure Resident #66's OOH-DNR was completed accurately. 2. The facility did not ensure Resident #225 had a physician order for her preferred code status. 3.The facility did not ensure Resident #225's code status was readily available to facility staff. These failures placed the residents at risk of not having their end of life wishes honored. Findings included: 1. Record review of Resident #66's face sheet dated [DATE], indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included fracture of right lower leg, diabetes type 2 (long term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressure), and dementia (memory loss). The face sheet indicated under the advance directive…

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 residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #22) of 23 residents reviewed for privacy and confidentiality. The facility failed to ensure MA R closed Resident #22's EMR before entering the supply room and leaving the medication cart unattended. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: Record review of Resident #22's face sheet dated 10/16/2024, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (a group of diseases that result in too much sugar in the blood), bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity level), and anxiety (a mental illness that causes excessive and uncontrollable feelings of fear or anxiety 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 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 1 of 23 residents (Resident #233) reviewed for abuse. The facility failed to ensure RN N did not verbally abuse Resident #233 on 09/21/2024. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 10/17/2024 indicated Resident #233 was a [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included displaced spiral fracture of shaft of right tibia (right fracture of the shin bone). Record review of the 5-day MDS assessment dated [DATE] indicated Resident #233 was able to understand others and was understood by others. The MDS assessment indicated Resident #233 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 23 residents (Resident #233) reviewed for abuse. The facility failed to implement their policy on reporting abuse when CNA H did not immediately report RN N's verbal abuse towards Resident #233 on 09/21/2024. The facility failed to follow its policy when RN N did not complete abuse training. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life. Findings included: Record review of a face sheet dated 10/17/2024 indicated Resident #233 was a [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included displaced spiral fracture of shaft of right tibia (right fracture of the shin bone). Record review of the 5-day MDS assessment dated [DATE] indicated Resident #233 was able to understand others and was understood by others. The MDS…

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

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, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 23 residents (Resident #233) reviewed for abuse reporting. The facility failed to ensure CNA H immediately reported RN N's verbal abuse towards Resident #233 on 09/21/2024 to the abuse coordinator or designee. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 10/17/2024 indicated Resident #233 was a [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included displaced spiral fracture of shaft of right tibia (right fracture of the shin bone). Record review of the 5-day MDS assessment dated [DATE] indicated Resident #233 was able to understand others and was understood by…

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 interviews and record review the facility failed to develop and implement the baseline care plan that included the minimum healthcare information necessary to properly care for a resident including, but not limited to - initial goals based on admission orders and physician orders for 1 of 4 (Resident #225) residents reviewed for baseline care plans. The facility did not ensure Resident #225's preferred code status was addressed on the baseline care plan. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: Record review of the face sheet, dated 10/16/2024, revealed Resident #225 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), schizoaffective disorder, bipolar type (a mental illness that is…

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 review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 4 residents reviewed for ADLs. (Resident #224) The facility failed to ensure Resident #224 was assisted with facial hair removal. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem. The findings included: Record review of the face sheet, dated 10/17/2024, revealed Resident #224 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behaviors (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The face sheet further revealed Resident #224 was receiving hospice services. Record review of the admission MDS assessment, dated 10/09/2024, revealed Resident #224 had clear speech and was understood by others.…

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 residents fed by enteral means received the appropriate treatment and services to prevent complications for the facility's only resident with an enteral device (Resident #57). The facility failed to ensure LVN W checked Resident #57's gastrostomy placement (placement of the tube used for nutrition and medication administration) as ordered by the physician on 10/15/24. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: Record review of Resident #57's face sheet dated 10/17/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), essential hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), gastrostomy…

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 review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 3 residents (Residents #43 and Resident #56) reviewed for respiratory care. 1. The facility failed to ensure Resident #56's oxygen concentrator was set at 2 liters per nasal cannula as ordered by the physician. 2. The facility failed to ensure Resident #43's oxygen concentrator was clean. These failures could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications. Findings included: 1. Record review of a face sheet dated 10/17/2024 indicated Resident #56 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 7 residents reviewed for pharmacy services. (Resident #57) The facility failed to ensure LVN W did not prepare to and attempt to administer Resident #57's metoprolol (blood pressure medication) his blood pressure was low on 10/15/24. The facility failed to ensure LVN W prepared and attempt to administer Resident #57's Eliquis (anticoagulant medication) on 10/15/24. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #57's face sheet dated 10/17/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), essential hypertension (high blood pressure), congestive heart failure…

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.

2. During an observation and interview on 10/16/24 at 4:28 PM, the MDS Coordinator entered Resident #176's room to flush her PICC line. The MDS Coordinator completed the procedure and went to the treatment cart to obtain disinfectant wipes to clean Resident #176's bedside table. The MDS Coordinator did not lock the treatment cart when she went back inside Resident #176's room to disinfect Resident #176's bedside table and wash her hands. The MDS Coordinator said it was her responsibility to lock the carts when leaving them unattended because residents could get in and get medications. Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 3 of 6 medication carts (treatment cart, 300-400 hall medication cart, and 100-200 nurses' cart) reviewed for pharmacy services. 1. The facility failed to ensure RN D locked the 100-200 nurses' cart when she left it unattended at the nurses' station on 10/14/24. 2. The facility failed to ensure the MDS Coordinator locked 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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #14) reviewed for hospice services. The facility did not ensure Resident #14's hospice records were a part of their records in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: Record review of the face sheet, dated 10/17/2024, revealed Resident #14 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of parkinsonism (clinical syndrome characterized by the four motor symptoms…

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 failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for 1 of 6 (RN N) employees reviewed for staff training. The facility failed to ensure RN N received abuse training. This failure could place residents at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training. Findings included: During an interview on 10/16/2024 at 10:20 AM, the DON said the facility did a lot of training on abuse upon hire and the facility provided frequent in-services on abuse. The DON said for staff that was employed through an agency the agency did their abuse training and checked their backgrounds. The DON said they tried to in-service the agency staff when they gave in-services about abuse and agency staff were present in the facility at the time of the in-service. The DON…

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 the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 3 of 6 residents reviewed for pharmacy services. (Resident #2, Resident #3, Resident #4) 1. The facility failed to ensure Resident #2 was administered her Nifedipine (medication to treat high blood pressure and chest pain) on 4/12/24 when it was available in the facility's emergency kit. 2. The facility failed to ensure MA D administered Resident #3 only her ordered medication and did not administer Trazodone (anti-depressant medication) and Ativan (anti-anxiety medication) without orders on 6/25/24. 3. The facility failed to ensure MA C administered Resident #4 her amlodipine (medication to high blood pressure and chest pain) on 7/18/24. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings Include: 1.…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 staff (CNA A and CNA B) observed for infection control. 1. The facility failed to ensure CNA A did not wipe Resident #1's vaginal area with a wipe visibly soiled by feces during incontinent care on 7/17/24. 2. The facility failed to ensure CNA B performed hand hygiene between glove changes, before exiting resident room, and prior to re-entering a resident room. 3. The facility failed to ensure CNA A and CNA B emptied the trash in Resident #1's room which had dirty gloves visibly soiled with feces following incontinent care and prior to exiting the resident's room. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. During an observation on 7/17/24 at 10:50 a.m. CNA A…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchens reviewed for food safety requirements. The facility failed to ensure 3 skillets were free from encrusted carbon buildup on the outside and half of the inside of the cooking surface. The facility failed to prepare over easy fried eggs with pasteurized eggs. The facility failed to ensure [NAME] P wore her hairnet when entering the kitchen during meal service. These failures could place residents at risk for foodborne illness. Findings included: During an observation on 9/11/2023 at 9:40 a.m., the dishrack had three skillets of varying sizes with encrusted carbon buildup on the outside surface and half of the inside cooking surface. During an observation on 9/11/2023 at 9:43 a.m., the refrigerator had 3 (30 count) flats and ½ of a (30 count) flat of brown eggs. The brown eggs did not have the P stamped on the eggs indicating pasteurized eggs. During an interview on 9/11/2023 at 9:50 a.m., 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 ensure that all alleged violations involving abuse were reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #249) of 6 residents reviewed for reporting allegations of abuse. The facility failed to report Resident #249's allegation of abuse to HHS. This failure could place the residents at risk for further potential abuse due to unreported allegations of abuse, and neglect. Findings included: Record review of Resident #249's face sheet, dated 09/05/23 indicated Resident #249 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), dementia (the loss of cognitive functioning - thinking,…

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 interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team for 1 of 15 residents (Resident #40) reviewed for care planning. The facility failed to ensure Resident #40 had a person-centered care plan for activities. This failure could place residents at risk for social isolation, depression, and a decreased psychosocial well-being. Findings included: Record review of a face sheet dated 9/15/2023 indicated Resident #40 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of legal blindness, depression, and anxiety. Record review of an admission MDS dated [DATE] indicated Resident #40 was understood, and usually understands. The MDS indicated Resident #40's vision was severely impaired with no vision or sees only light, colors, or shapes. The MDS indicated Resident #40's BIMS score was 9 indicating his cognition was moderately impaired. Record review of Resident #40's care area summary failed to reflect…

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 promptly notify and follow-up with the ordering physician regarding laboratory results outside of clinical reference range for 1of 1 residents reviewed for laboratory services. (Resident #41). The facility failed to implement timely treatments for Resident #41's urinary tract infections. This failure could place residents at risk for urinary tract infections as well as any other urinary/incontinence issues. Findings included: Record review of a face sheet dated 9/13/2023 indicated Resident #41 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of dementia, and the need for assistance with personal care. Record review of an Annual MDS dated [DATE] indicated Resident #41 usually understood and was understood by others. Record review of the MDS indicated Resident #41's BIMS score was 3 indicating she had severely impaired cognition. The MDS indicated Resident #41 required limited assistance of one staff with toilet use and personal…

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 food that was palatable for 1 of 15 resident (Resident #18) reviewed for palatable food and 1 of 1 test trays. The facility failed to provide palatable food served at an appetizing taste to Resident #18 who complained of the food not tasting good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 9/11/2023 at 10:04 a.m., Resident #18 said the food could be better as far as flavor. Resident #18 had not spoken to anyone regarding the food. Resident #18 ate in her room. During an observation and interview on 9/12/2023 at 12:45 p.m., a lunch tray was sampled tby the DM and 4 surveyors. The sample tray consisted of Mexican rice, chicken fajita, fajita vegetables, and apple sauce. The DM said the rice was gooey with hard bits throughout. The DM said the fajita vegetables tasted bland. The DM said the cook boiled the rice before placing on the steam table. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 2 residents (Resident #23) reviewed for preference. The facility failed to honor Resident #23's preferences for a vegan diet. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #23's face sheet, dated 09/05/23 indicated Resident #23 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Diabetes mellitus (a group of diseases that affect how the body uses blood sugar), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and anxiety (feelings of nervousness, panic, and fear). Record review of Resident #23's quarterly MDS assessment, dated 09/02/23, indicated Resident #23 was understood and understood others. Resident #23's BIMs score was 13, which indicated she was cognitively intact. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain the most recent plan of care specific to each resident for 3 of 3 residents (Resident #'s 4, 38, and 249) reviewed for hospice services. The facility failed to obtain Resident #38's, Resident # 4's and Resident #249's most recent hospice plan of care. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: 1. Record review of Resident #38's face sheet date 09/14/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #38's diagnoses included diabetes (a group of diseases that result in too much sugar in the blood), urine retention (a condition in which all the urine from the bladder cannot be emptied), anxiety, congestive heart failure (a long-term condition in which the heart can't pump blood well…

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 failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 7 of 21 employees (RN F, RN G, Speech Therapist, Occupational Therapist, CNA H, CNA K, and CNA L) reviewed for required trainings. The facility failed to ensure RN F, RN G, CNA H, CNA K and CNA L received restraint and HIV training upon hire. The facility failed to ensure the Speech Therapist received HIV training annually. The facility failed to ensure the Occupational Therapist received restraint and HIV training annually. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no HIV or restraint training completed upon hire for the following staff: *RN F (hire date 08/16/23), *RN G (hire date 07/05/23), *CNA H (hire date 02/15/23), *CNA K (hire date 03/17/23), and *CNA L (hire date 03/17/23). . Record review of the employee files revealed there was no HIV or…

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.