Avir at Heritage Oaks

Based on observation, interview and record review, the facility failed to provide food and drink that was palatable, attractive and at a safe and appetizing temperature for 5 residents (Residents #8, #60, #99, #101, and 1 confidential resident) reviewed for food palatability. one of one kitchen. A. Resident #8, #60, #99, #101 voiced concerned of cold food, flavor and/or texture.B. Nine of the 9 foods sampled on the meal tray were cold.C. One of the 9 foods sampled on the meal tray was mushy.D. Three of the 9 foods sampled on the meal tray had no flavor. E. Three of the 9 foods sampled on the meal tray were chunky. F. One of the 9 foods sampled on the meal tray was tough. These failures could result in a decline in residents' consumption of food and residents to have unwanted weight loss. The findings included: During an interview on 05/04/2026 at 2:37 PM, Resident #99 was asked how the food was and he responded by saying Some of them are not really good, no flavors, no taste. He stated that he ate at the dining. During an interview on 05/04/2026 at 2:49 PM, Resident #101 was asked…

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 service safety in facility 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerator (x1), and freezer (x1), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the garbage can used for food waste was covered unless in use. 3) The facility failed to ensure the hair restraint was properly worn. 4) The facility failed to ensure the dish and pot washing area were clean. These failures could place residents at risk for food-borne illness and cross contamination.The findings included: During kitchen tour observations on 05/04/2026 that began at 9:34 a.m. and concluded at 10:15 a.m., revealed the following: -Garbage can, next to food prepping table, was uncovered and not in use. -Cook A, not properly wearing hair restraint to cover his mustache area. -Dirty black food residues under the pot & pan sink/draining…

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

Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (#1 and #2), in that: The door for dumpster #2 was left open.Garbage and debris in the vicinity of the 2 dumpsters. These failures could place residents at risk of exposure to germs and diseases carried by vermin and rodents.The findings included: Observation on 05/04/2026 at 10:21 a.m., revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial-size dumpster 3/4 full of garbage, with an open door (#2) and bags full of garbage on the floor around the dumpsters #1 and #2. During an interview on 05/06/2026 at 11:50 a.m., the DM stated, Everyone in the facility is responsible for keeping the dumpster area clean and closing the door, if you see a trash bag on the ground, pick it up and throw it into the dumpster. All staff members were responsible for monitoring such task. She further stated, I can't answer why the bags of garbage were on the floor because I don't know why. She stated, I have never had any…

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 and 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 residents (Resident #58 and Resident #29) reviewed for infection control. CNA D failed to utilize EBP and hand hygiene during foley catheter (a flexible, sterile tube inserted into the bladder to drain urine, held in place by an inflated balloon) care on Resident #58.CNA E failed to utilize glove change and hand hygiene during incontinence care on Resident #29. These failures could place residents at risk for cross contamination and infection. Findings included:Resident #58Record review of Resident #58 undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #58 had a medical diagnoses of cerebral infraction (a blockage (clot or plaque) reduces blood flow to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for respect and dignity.CNA C failed to provide privacy to Resident #1 when CNA C left Resident #1 naked in bed with the door open on 3/15/2026.This failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem. Findings include:Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #1 had a medical history of chronic kidney disease, malignant neoplasm of the spinal cord (a cancerous tumor arising within or spreading to the spine), and paraplegia (impairment of motor and sensory function in the lower half of the body).Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated Resident #1 was cognitively intact. Section GG- Functional abilities revealed Resident #1 was dependent on…

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 reviews, the facility failed to ensure residents were free from abuse and/or neglect for 1 of 6 residents (Resident #1) reviewed for abuse and/or neglect.MM A told Resident #1 to get the fuck out of my face on 3/20/2026.This failure could cause residents emotional distress, a decrease in their health conditions, or exacerbation of their health conditions.Findings include:Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #1 had a medical history of chronic kidney disease, malignant neoplasm of the spinal cord (a cancerous tumor arising within or spreading to the spine), and paraplegia (impairment of motor and sensory function in the lower half of the body).Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated Resident #1 was cognitively intact.Resident #2Record review of Resident #2's face sheet revealed a [AGE] year-old male, originally…

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 develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 7 residents reviewed for comprehensive care plans. The facility failed to revise Resident #1's care plan, a resident with an active Stage IV pressure ulcer, to reflect the use of a pressure-relieving mattress that was ordered by the physician on 11/8/25. This failure could place residents at risk for unclear staff guidance, inconsistent implementation of care, inadequate monitoring, delayed wound healing, and potential worsening or development of additional pressure injuries.Findings included:Record review of Resident #1's face sheet, dated 1/05/26, revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses to include…

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 follow their own established smoking policy for 1 of 7 residents reviewed for smoking. (Resident #1)The facility failed to ensure Resident #1 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) at his bedside. This failure could place residents at risk of injury or harm.Findings included:Record review of Resident #1's face sheet undated indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinsons (brain disorder), anxiety (feeling of fear and worry), hypertension (high blood pressure) and weakness.Record review of Resident #1's annual MDS assessment dated [DATE], indicated he had a BIMS score of 14, which indicated he had intact cognition. The MDS indicated Resident #1 was independent or needed set-up/clean-up assistance for most ADLs. The MDS indicated Resident #1 was using tobacco at the time of the assessment.Record review of Resident #1's…

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

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 19 of 22 confidential residents. The facility failed on 03/07/2025 to ensure 19 of 22 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews and Record Review during Resident Council on, 03/06/2025 at 10:30am, 19 of 22 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting 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 maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 4 of 6 residents (Resident #2, Resident #63, Resident #71, and Resident #86) and 3 of 3 staff (LVN E, CNA H, CNA I) reviewed for infection control. 1. CNA H failed to follow policy and procedure for handwashing while providing peri care for Resident #2, during observations of peri care on 03/06/2025 at 1:42 PM. 2. LVN E failed to follow policy and procedure for handwashing while providing wound care for Resident #63, during observations of wound care on 03/05/2025 at 11:33 AM. 3. CNA I failed to follow policy and procedure for handwashing while providing peri care for Resident #71, during observations of peri care on 03/05/2025 at 10:50 A. 4, LVN E failed to follow policy and procedure for handwashing while providing wound care for Resident #86, during…

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 promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 32 residents (Resident #98) reviewed for dignity issues: The facility did not place a urinary catheter drainage bag in a privacy bag to screen/cover it from view for Resident #98 on 03/06/2025 and 03/07/2025. This failure placed residents in the facility, with urinary catheters, at risk of feeling uncomfortable or embarrassed and decreased privacy. Findings included: Record review of Resident #98's admission Record dated 03/7/2025, a [AGE] year-old male with an admission date of 11/08/2024, with diagnoses that included the following: Osteomyelitis (a bone infection that happens when bacterial or fungal infections spread from other parts of your body into bone marrow); Pathological fracture (when force or impact didn't cause the break to happen, instead, an underlying disease leaves bones weak) , left femur (thigh…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 32 residents (Resident #2,) reviewed for Respiratory Care. 1. The facility failed to follow physician's orders indicating Resident #2's oxygen humidification bottle should be monitored every shift and replaced or refilled as needed on 03/05/2025. 2. The facility failed to follow physician's orders indicating Resident #2's nasal cannula and oxygen tubing should be changed weekly on 03/05/2025 and 03/06/2025. These deficient practices have the potential to affect residents by placing them at an increased risk of respiratory infection, respiratory distress, and a diminished quality of life. Findings include: Resident #2 Record review of Resident #2's face sheet dated 03/07/2025 revealed a [AGE] year-old male with an admission date of 01/19/2023 and included the following diagnoses: Acute respiratory 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to change gloves and wash hands while preparing snack sandwiches on 03/05/2025 at 11:15 AM. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During an observation on 03/05/25 at 11:15 AM DA A was preparing sandwiches on prep table. DA A had gloves on. DA A left the prep table with gloves on and walked to the dry storage room. DA A returned to prep table with same gloves on and opened bag of potato chips and using gloves hand put potato chips in Styrofoam container with sandwich. DA A put right gloved hand into pocket to get sharpie marker. DA A wrote on Styrofoam container and placed marker back in pocket. DA A left prep table with gloves on and went into DM office. DA A returned to prep table with same gloves on and being preparing sandwiches placing them on…

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 maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 residents (Residents #2 and #3) reviewed for infection control. 1. CNA A failed to utilize proper hand hygiene during incontinence care for Resident #2 2. CNA B failed to utilize proper hand hygiene during incontinence care for Resident # 3. These failures could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #2's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had a history of Dementia (impaired ability to remember), generalized anxiety disorder, and hypertension (high blood pressure). Record review of Resident #2's MDS dated [DATE], Section C Cognitive patterns revealed Resident #2 had a BIMs score of 08 which indicated the resident had moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 2 of 2 resident for dignity and catheter care (Resident #64 and Resident #106); in that: 1. The facility failed to ensure respect and dignity to Resident #64 by LVN D knowingly leaving him lying in feces for over an hour, when he had a bowel movement during wound care. 2. The facility failed to place catheter tubing off the floor and place a cover on the catheter. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings include: Record Review of Resident #64's face sheet revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with a readmit…

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 respect the resident's right to personal privacy for 3 of 3 residents (Resident #102, #106, and #276) reviewed for privacy issues in that: 1. Housekeeper failed to knock and introduce herself prior to entering Resident #276 room. 2. NA failed to provide privacy by not pulling curtain all the way for Resident #102 during perineal care. 3. LVN E failed to pull the privacy curtain while providing wound care for Resident #102. 4. LVN G failed to pull the privacy curtain while providing wound care for Resident #106. This failure could cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by. Findings include: Record Review of Resident #102 face sheet dated 2/22/2024 reveals a [AGE] year-old female, originally admitted on [DATE] with a primary diagnosis of fracture of shaft on left tibia, reduced mobility, thrombocytopenia (low platelet level), high blood pressure, heart failure, pleural effusion (buildup…

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

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were accurately acquired, received, dispensed, and administered in accordance with currently accepted professional standards for 2 of 3 medication carts (Wildflower Cart A and B) , 2 of 2 medication rooms (Wildflower Med room A and Rapid med room B) and 1 of 1 treatment cart (Treatment cart A) reviewed. 1. The facility failed to ensure that all medical supplies stored in Cart A were not past their expiration date. 2. The facility failed to ensure that all medication stored in Cart B were not past their expiration date. 3. The facility failed to ensure that all medication stored in Medication room A were not past their expiration date. 4. The facility failed to ensure that all treatment supplies and medication in Treatment Cart A were not past their expiration date. 5. The facility failed to ensure all medical supplies in Medication room B were not past their expiration date. These failures placed all residents at risk of harm or decline in health due to…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 3 medication carts (Sunflower cart C), and 1 of 2 medication rooms (Rapid med room B) reviewed. 1. The facility failed to ensure proper temperature documentation of the refrigerator in Medication room B. 2. The facility failed to ensure all medication in Medication Cart C were properly labeled. These failures placed all residents at risk of harm or decline in health due to lack of medication labeling, and inadequate temperature monitoring. The findings include: During an observation of Medication Room B on 2/21/2024 at 11:15 AM it revealed the medication storage refrigerator in Medication room B had a temperature log dated 12/2023. The last checked temperature on 12/5/2023 with a logged temperature of 39 degrees Fahrenheit. Record review of documentation labeled Temperature Log for Refrigerator-Fahrenheit dated 12/23 revealed a logged temperature for dates…

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 attractive for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable and attractive for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (2/21/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 9 of 32 residents voiced concerns related to food palatability and appearance. One Resident stated that the food it's crap to me. She stated she did not like the flavor and texture. Another Resident stated the food was horrible. It's cold it has no flavor, and the squash was mushy. It floats on the plate . Yet another Resident had concerns with food palatability. She stated, I don't like the food. One Resident said the presentation of the food was not good and did not look good. He stated that his family brings him…

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 and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 4 of Residents (Resident #52, #61, #72, and #102) observed for infection control for 4 0f 8 resident's reviewed for infection control practices (Resident #52, #61, #72, and #102). 1. CNA A failed to wash her hands before, during, and after incontinent care of Resident #52. 2. LVN E failed to wash her hands properly. She turned on water, placed soap on hands, and immediately started washing hands under running water and not allowing soap to lather. LVN E used a dirty paper towel to turn off the faucet after wound care for Resident #102. 3. NA failed to wash her hands before, during, and after incontinent care for Resident #102. 4. LVN A did not sanitize the blood pressure cuff before or after use on Resident #61.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from neglect for 1 of 1 resident (Resident #64), reviewed for neglect when LVN D failed to provide incontinent care services to Resident #64 in a timely manner. LVN D neglected Resident #64 by failing to provide incontinent care when Resident #64 had a bowel movement during wound care when LVN D was aware of R#64's bowel incontinent episode. This failure could affect all residents by placing them at risk of abuse neglect, skin breakdown, mental anguish, emotion distress, infections, and possible serious harm. Findings include: Record Review of Resident #64's face sheet revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with a readmit date of 09/07/2023 with the following diagnoses of: type 2 diabetes with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), pressure ulcer of the sacral region (stage 4), acute kidney…

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 reviews the facility failed to notify, consistent with his or her authority, the resident representative(s) for 2 of 6 sampled residents (Resident #1 and Resident #4) when there was a significant change. LVN A failed to document notification of Family Member A or Family Member B when Resident #1 developed new open areas on his skin. LVN B and LVN A failed to document notification of Resident #4's Family Member C when he had a change of condition, and new orders were received. This deficient practice had the potential to place residents at risk for not having their family or legal representative notified when having a change of condition. The findings include: Resident #1 Record review of Resident #1's undated facesheet revealed a [AGE] year-old male that was admitted to the facility on [DATE] with the following diagnosis of hemiparesis (muscular weakness) following cerebral infarction (disrupted blood flow to the brain) affecting right dominant side, nontraumatic intracerebral…

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.