The Bradford At Brookside

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 6 residents reviewed for resident rights. (Resident #1) The facility failed to ensure CNA C did not put her fingers in Resident #1's face. This failure could cause the resident to be distressed and could cause residents to feel disrespected. Findings included: Record review of Resident #1 face sheet dated 05/19/25 indicated a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #1 had diagnoses including alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die), anxiety disorder, dysphagia following cerebral infarction (difficulty swallowing), dysphagia oral phase (difficulty with the initial stages of swallowing) and schizophrenia (a disorder that affects a person's ability to think feel, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from abuse when CNA C put her fingers in Resident #1's face. This failure could cause the residents at risk of disrespect, mental anguish, and/or emotional distress. Findings included: Record review of Resident #1 face sheet dated 05/19/25 indicated a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #1 had diagnoses including alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die), anxiety disorder, dysphagia following cerebral infarction (difficulty swallowing), dysphagia oral phase (difficulty with the initial stages of swallowing) and schizophrenia (a disorder that affects a person's ability to think feel, and behave…

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 with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #2) reviewed for pressure injury. The facility failed to ensure the Treatment Nurse measured and adequately documented Resident #2's wound in the EMR when it was initially found on 05/15/2025. These failures could place residents at risk for deterioration of wounds. Findings included: Record review of Resident #2's face sheet dated 05/19/25 indicated a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #2 had diagnoses including major depressive disorder (a serious mental illness characterized by persistently low mood, loss of interest or pleasure in activities, and other symptoms like changes in sleep, appetite and energy), down syndrome (a genetic chromosome 21 disorder…

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 right to formulate an advance directive was provided for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility did not have a DNR order when Resident #1 provided a copy of his Advanced Directive upon admission. The facility did not provide emergency medical technician and hospital personnel with any information relating to Resident #1's known existing advance directive. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE]. Record review of Physician Orders 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 observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 20 residents reviewed for range of motion. (Resident #66) The facility did not ensure Resident #66's palm guard (device used as a barrier between fingers and palmar skin to prevent injury to the palm from severe finger flexion contracture) was placed in her hands bilaterally, after therapy assessed the resident's needs and referred the resident to restorative care. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of physician orders dated July 2024 indicated Resident #66, admitted [DATE], was a [AGE] year-old female with diagnoses of diabetes and benign neoplasm of the cranial nerve (a rare type 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 residents who entered the facility with an indwelling catheter were assessed for removal of the catheter as soon as possible and restore continence to the extent possible for 1 of 2 residents reviewed for urinary catheters. (Resident #275) The facility failed to attempt bladder retraining and discontinuation of an indwelling urinary catheter (a tube which is inserted into the bladder, through the urethra and remains in place to drain urine) for Resident #275 whose clinical condition did not necessitate catheterization. This failure could place residents with a urinary catheter at increased risk of dependence on a urinary catheter and urinary tract infections. Findings included: Record review of physician orders dated July 2024 indicated Resident #275, admitted [DATE], was a [AGE] year-old female with diagnoses of respiratory failure (a serious condition that makes it hard to breathe on your own) and anoxic brain damage (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 a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 20 residents reviewed for respiratory care and services. (Resident #66) *The facility failed to administer the correct dose of oxygen to Resident #66. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated July 2024 indicated Resident #66, admitted [DATE], was a [AGE] year old female with diagnoses of chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues of your blood or when there is too much carbon dioxide in the blood) and a tracheostomy (a surgical opening into the windpipe to allow air to fill the lungs). The resident was…

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

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 to each resident for 1 of 7 residents reviewed for medications. (Resident #175) The facility failed to ensure Resident #175 was not administered a saline IV flush before administration of an IV antibiotic and an IV saline and an IV heparin flush after medication administration (SASH-saline administer, saline heparin) without a physician's order. This deficient practice could place residents at risk of consuming unprescribed medications, harm, and hospitalization. Findings included: Record review of Resident #175's face sheet indicated she was a [AGE] year-old-female admitted [DATE] with a diagnosis of UTI. She was to receive Piperacillin/Tazobactam (a penicillin antibiotic used to treat bacterial infections) 3.375 gm/NS 200 ml at 200 ml per hour via midline IV…

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 employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 9 dietary staff (Dietary Staff B) reviewed for competencies. The facility failed to ensure Dietary Staff B had a current Food Handlers Certificate while working in the facility's kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. Findings included: Record review of 9 dietary staff food handlers certificates indicated Dietary Staff B's certificate was expired on 07/15/24. During an interview on 07/23/24 at 11:00 a.m., the DM said Dietary Staff B had worked a day or two with an expired food handler certificate. During an interview on 07/23/24 at 11:30 a.m., the HR staff said the food handler certificate was important for the dietary staff to renew their food handler certificate to obtain the latest training to prevent food born borne illnesses and handle food correctly.…

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 Resident #51 FTag Initiation Based on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for 5 (Resident #23, #28, #38, #42 and #51) of 16 residents reviewed for care planning. The facility failed to ensure the IDT, Resident #23, Resident #28, and Resident #38 and RP of Resident #38, Resident #42 and the RP of Resident #42, Resident #51 and RP of Resident #51 were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings included: 1. Record review of 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 promote resident self-determination through support of resident choice for 1 of 22 residents reviewed for resident rights. (Resident #19) The facility did not assist Resident #19 out of bed when he requested. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of the face sheet dated 06/13/23 indicated Resident #19 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, anxiety disorder, and reduced mobility. Record review of the MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #19 was cognitively intact. The MDS indicated Resident #19 required extensive assistance with bed mobility and was totally dependent on staff for transfers. Record review of a care plan revised on 02/22/23 indicated Resident #19 had…

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 the necessary services to maintain personal hygiene for 3 of 22 residents reviewed for ADLs (Resident #17, Resident #19, and Resident #219). The facility failed to provide scheduled baths/showers for Resident #17 and Resident #19. The facility failed to trim and clean Resident #219 nails. These failures could place residents who required assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of the face sheet dated 06/13/23 indicated Resident #17 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, history of colon cancer, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident #17 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #17 was cognitively intact. The MDS indicated Resident #17 required supervision with one-person physical assist…

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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 22 residents reviewed for resident rights. (Resident #19) The facility failed to close the blinds to the outside window while providing incontinent care to Resident #19. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of the face sheet dated 06/13/23 indicated Resident #19 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, anxiety disorder, and reduced mobility. Record review of the MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #19 was cognitively intact. The MDS indicated Resident #19 required limited to extensive assistance from staff for activities of daily living. 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 observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 22 residents (Resident #225) reviewed for reasonable accommodations. The facility failed to provide an appropriately sized bedside commode for Resident #225. This failure could place residents at risk for unmet needs. Findings included: Record review of a face sheet dated 06/13/23 revealed Resident #225 was a [AGE] year-old female admitted on [DATE] with diagnosis including presence of right artificial ankle joint (is where your shin bone (tibia), calf bone (fibula) and talus bone meet). Record review of the MDS revealed Resident #225 was admitted to the facility less than 21 days ago. No MDS for Resident #225 was completed prior to exit. Record review of an undated baseline care plan revealed Resident #225 was alert/cognitively intact, and continent of urine and bowel. The baseline care…

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 an accurate MDS assessment was completed for 1 of 14 residents reviewed for MDS accuracy. (Resident # 51 and #43) 1. The facility failed to accurately document Resident #51's and Resident #43's wander/elopement alarm usage. These failures could place residents at risk for not receiving needed care and services. Findings included: 1. Record review of Resident# 51's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Unspecified Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), adjustment disorder with anxiety (nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed), muscle weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy.), unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), lack 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 interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 3 residents reviewed for new admissions (Resident #225). The facility failed to ensure Resident #225 completed her baseline care plan within 48 hours of admission and was provided a written summary. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 06/13/23 revealed Resident #225 was a [AGE] year-old female admitted on [DATE] with diagnoses including presence of right artificial ankle joint (is where your shin bone (tibia), calf bone (fibula) and talus bone meet), Type 2 diabetes (is a disease that occurs when your blood glucose, also called blood sugar, is too high), depression (is a mood disorder that causes a persistent feeling of sadness…

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 resident who was incontinent of bladder and entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible for 1 of 2 residents (Resident #226) reviewed for catheter use. The facility failed to remove Resident #226's indwelling catheter after admission due to no appropriate diagnosis of use. This failure placed resident at risk for urinary tract infection (is an infection in any part of your urinary system, which includes your kidneys, bladder, ureters, and urethra) and inappropriate treatment and services. Findings included: Record review of a face sheet dated 06/13/23 revealed Resident #226 was a [AGE] year-old female admitted on [DATE] with diagnoses including hemiplegia (is paralysis that affects one side of your body) following cerebral infarction (stroke) and gastrostomy (is a tube inserted through the belly that brings nutrition directly to the stomach). The face sheet did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 22 residents reviewed for respiratory care. (Resident #22, Resident #60). The facility failed to ensure Resident #22's nebulizer mask and tubing was properly stored and dated per the facility's policy. The facility failed to assist Resident #60 with putting on and taking off her Bipap machine (a form of non-invasive ventilation that providers might use if you can breathe on your own but are not getting enough oxygen or cannot get rid of carbon dioxide). These failures could place residents at risk of respiratory complications or respiratory infection. Findings included: 1. Record review of an undated face sheet revealed Resident #22 was a [AGE] year-old, male, and admitted on [DATE] with diagnoses including respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), acute and chronic…

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, interview and observation the facility failed to ensure 1 of 22 residents reviewed for psychotropic medications were given the meds to treat a specific condition. The facility failed to have an appropriate diagnosis or indication of use for Resident #38's Risperdal (antipsychotic). This failure could put residents at risk of receiving unnecessary psychotropic medications. Findings included: Record review of Resident 38's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), dementia (group of thinking and social symptoms that interferes with daily functioning), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Record review of Resident # 38's annual MDS, dated [DATE], reflected she had a BIMS score of 04, which indicated severe impaired cognitive status. Her…

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 provide specialized rehabilitative services for 1 of 22 residents reviewed for specialized rehabilitative services. (Resident #62) The facility failed to ensure Resident #62 received occupational therapy and as per physician orders after being readmitted to the facility. This failure could place residents with orders for therapy at risk of not meeting their highest practicable well-being. Findings include: Record review of the face sheet dated 06/13/23 indicated Resident #62 was [AGE] years old and admitted on [DATE] with diagnoses including cerebral infarction (stroke), muscle weakness, and history of falling. Record review of Physician's Orders for Resident #62 dated June 2023 indicated an order dated 05/30/23 that indicated, Therapy - OT Clarification Order. Skill OT (occupational therapy) 3x/wk x 4 weeks (3 times a week for 4 weeks) .including therapeutic exercise, therapeutic activities, neuromuscular re-education, balance/safety training,…

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 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 22 residents (Residents #19 and Resident #223) reviewed for infection control practices. The facility to ensure the WCN performed a sterile dressing change on Resident #223. The facility failed to ensure CNA D changed gloves and practiced good hand hygiene during incontinent care provided to Resident #19. These failures placed residents at risk for cross contamination and infection. Findings include: 1. Record review of a face sheet dated 06/13/23 revealed Resident #223 was an [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke) due to thrombosis (blood clot) and pain. Record review of Resident #223's consolidated physician order dated 06/01/23 revealed wound treatment- calcium…

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.