Merkel Nursing Center

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 4 of 16 (the DM, LVN E, NA G, and NA H) staff reviewed for training on resident's rights. The facility failed to ensure that the DM, LVN E, NA G, and NA H were educated on the rights of the resident, and the responsibilities of the facility to properly care for its residents upon hire.This failure could place residents at risk of their rights not being honored by uninformed staff.The findings were:Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of personnel record provided by the AIT reflected the DM had no evidence that she had completed required resident rights training upon hire or while working at the facility.Record review of the personnel records for LVN E reflected a hire date of 6/20/2025. Further review of the personnel record provided by the AIT reflected LVN E had no evidence that she had completed required resident rights training upon hire or while working at…

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 an effective training program for all new and existing staff for 3 of 16 (the DM, RN C, and NA G) staff reviewed for training on abuse, neglect, and exploitation and training for dementia management. The facility failed to ensure that NA G was educated on abuse, neglect and exploitation & dementia management upon hireThe facility failed to ensure that the DM and RN C were educated on dementia management upon hire. These failures could place residents at risk of being abused, neglected, or exploited by uniformed staff and could delay the facility's investigation of abuse, neglect, or exploitation. Findings were:Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence that she had completed neither the abuse, neglect, and exploitation training nor the dementia management training upon hire or while working at the facility.Record review of the personnel records for the DM…

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 an effective training program for all new and existing staff for 5 of 16 (the DON, the DM, RN C, LVN E, and NA G) staff reviewed for training on QAPI. The facility failed to ensure that the DON, the DM, RN C, LVN E, and NA G were educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program. Findings were:Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of the personnel record provided by the AIT reflected the DON had no evidence that she had completed QAPI training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of the personnel record provided by the AIT reflected the DM had no evidence that she had completed QAPI training upon hire or while working at…

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 an effective training program for all new and existing staff for 4 of 16 (the DON, the DM, LVN E, and NA G) staff reviewed for training on infection control. The facility failed to ensure that the DON, the DM, LVN E, and NA G were educated on infection control upon hire. This failure could place residents at risk of contracting facility acquired infections from staff not being informed on proper infection prevention and control practices when performing resident care activities that pertain to that staff member's role.Findings were:Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of the personnel record provided by the AIT reflected the DON had no evidence that she had completed infection control training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of the personnel record provided by the AIT reflected the DM had no evidence that she 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.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 3 of 16 (the DON, the DM, and NA G) staff reviewed for training on behavioral health. The facility failed to ensure that the DON, the DM, and NA G were educated on behavioral health upon hire. This failure could place residents diagnosed with a mental, psychosocial, or substance use disorder at risk of not receiving the care specific to their individual needs.Findings were:Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of the personnel record provided by the AIT reflected the DON had no evidence that she had completed behavioral health training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of the personnel record provided by the AIT reflected the DM had no evidence that she had completed behavioral health training upon hire or while working at the facility.Record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #7) of 12 residents reviewed for resident records.The facility failed to ensure Resident #7's physician order and face sheet matched Resident #7's care plan for DNR.This failure could place residents at risk of having CPR when they or their representatives have requested no CPR treatment.Findings included: Record review of Resident #7's electronic face sheet, dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (losing your memory and other thinking skills so much that it gets in the way of your daily life). Further review of face sheet reflected Resident #7was a Full Code status, meaning she would receive CPR if her heart stopped beating, or she stopped breathing. Record review of Resident #7's annual MDS, dated…

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 1 of 3 (NA G) staff reviewed for infection control. The facility failed to ensure NA G performed proper peri-care (incontinent care) for Resident #22. This failure could place residents at risk of infections from incontinent care. Findings included: Review of Resident #22's face sheet, dated 12/04/2025, revealed a [AGE] year-old female admitted on [DATE]. Resident #22's medical diagnoses included vascular dementia (impaired blood flow to the brain), insomnia (unable to sleep), local infection of the skin and generalized anxiety disorder. Record review of Resident #22's Annual MDS, dated [DATE], revealed in Section C - C0500, a BIMS score of 01 indicating the resident was severely cognitively impaired and unable to complete 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 interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 Dietary Manager (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility had a certified DM from July 21, 2025, until August 20, 2025. This failure could place residents at risk of not having their nutritional needs met and placed them at risk for food born illnesses.Findings included: Record review of the employee files revealed no evidence of a dietary manager. During an interview on 08/18/2025 at 11:30 AM DA R stated the facility currently did not have a DM. DA R stated that on July 21, 2025, the DM called in sick, and they had not heard anything else from the DM. DA R stated the facility had not hired another DM. During an interview on 08/18/2025 at 12:00 PM the Administrator in Training F stated the previous DM had left without putting in notice. Administrator in Training F stated she had been trying to hire a new DM but had not been able to hire…

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 be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, Resident #3) of 24 residents. 1. Resident #1 ingested harmful chemicals and was hospitalized on [DATE].2. Resident #2 left the facility unaccompanied and without facility knowledge on 07/04/2025.3. Resident #3 reported an allegation of abuse and the facility administration failed to follow internal policies.4. The facility's administrative personnel did not ensure the facility was administered by a full-time licensed administrator who was knowledgeable of regulations, facility policies, and procedures.5. The facility's administrative personnel did not ensure the Administrator In Training was being provided oversight. These failures placed residents at risk of physical and psychological harm due to lack of oversight 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 interview, and record review the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility. The facility failed in conducting the facility assessment to ensure involvement from nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.Findings included: In an interview on 8/15/25 at 1:29 pm, Administrator-in-Training F did not know what a facility assessment was, and Owner D stated she could not locate it. The Administrator-in-Training F stated she began working for the facility in January 2025. In an interview on 8/15/25 at 6:50 pm, Administrator-in-Training F stated what…

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 interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 2 of 5 employees (Administrator Q and ADON E) reviewed for employability.The facility failed to follow written policy of completion of criminal history check and an initial EMR/NAR check for ADON E prior to offering employment.The facility failed to follow written policy of annual EMR verification was completed for Administrator Q. These findings placed residents at risk of receiving care by someone that was unemployable.The findings included:Record review of ADON E's employee file revealed a hire date of 06/08/2025 and no evidence of criminal history or an EMR/NAR check were completed prior to offering employment. Record review of Administrator Q's employee filed revealed a hire date of 09/17/2021 and no evidence of annual EMR check completed. During an interview on 08/20/2025 at 10:30 AM, Administrator Q stated his expectation was criminal history and EMR checks…

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 2 (Resident #1, Resident #2) of 24 residents reviewed for allegations of neglect. 1. The facility failed to report when Resident #1 ingested harmful chemicals and was hospitalized on [DATE] to the State Survey Agency. 2. The facility failed to report when Resident #2 left the facility unaccompanied on 07/04/25 to the State Survey Agency and to the police. These failures could affect the residents in a decrease in physical health, injuries, additional hospitalizations, or death. Findings included: A record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report the results of all investigations to administrator and to other officials in accordance to State law, including to the State Survey agency, within 5 working days after the incident, and if the alleged violation is verified appropriate corrective action must be taken for 3 of 3 incidents reviewed. The facility failed to ensure the Administrator followed the facility's abuse/neglect policy, by not submitting the results of all investigations to the State Survey agency, within five (5) working days after the incident was reported, for: 1. The self-reported incident that involved Resident #9 when she suffered a mildly displaced fracture of the ankle on 07/23/2025.2. The self-reported incident that involved Resident #8 when she suffered a fall that required stitches to her left forehead on 07/08/2025. 3. The self-reported incident that involved Resident #3 when she suffered alleged abuse from a nurse at the facility 04/28/2025. These failures could…

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 1 of 6 residents (Resident #1) reviewed for infection control practices. CNA A and Nursing Aid B failed to perform proper hand hygiene and change gloves while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. The findings include: Record review of Resident #1's admission Record, dated 12/13/2024, revealed a [AGE] year-old female with an admission date of 03/02/2018. Resident #1 had a primary diagnosis which included Vascular Dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she…

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 records reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #10) of 3 residents reviewed for change of condition. The facility failed to notify Resident #10's physician after Resident #10's change in condition did not improve after she returned from the hospital. This failure could place residents at risk of not having their change of condition communicated to their physician, delay of treatment, and a decline in the residents' health and well-being. The findings include: Record review of Resident #10's Facesheet, dated 10/15/2024, revealed Resident #10 was a [AGE] year-old female, with an admission date into the facility of 06/11/2024. Diagnoses included Hypothyroidism (underactive thyroid), Depression (mood disorder that can affect…

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 records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #6, Resident #7, and Resident #10) of 7 residents reviewed for care plan accuracy, in that: Resident #6 and Resident #7 did not have a care plan that addressed smoking, and for Resident #10, the facility failed to develop a comprehensive care plan as required. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or cause injury or harm. The findings included: Resident #6 Record review of Resident #6's Facesheet, dated 10/10/2024, revealed Resident #6 was a [AGE]…

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 records reviews, the facility failed to maintain medical records on each resident that are complete and accurately documented, in accordance with accepted professional standards and practices for 3 (Resident #5, Resident #6, and Resident #7) of 3 residents reviewed for smoking assessments. The facility failed to completely and accurately document quarterly smoking assessments for Resident #5, Resident #6, and Resident #7 per facility smoking policy. This failure could place residents at risk of having incomplete and inaccurate records, which could lead to miscommunication and interruption of services. The findings included: Resident #5 Record review of Resident #5 Facesheet, dated 10/09/2024, revealed Resident #5 was a [AGE] year-old female, with an admission date into the facility of 12/17/2014. Diagnoses included Unspecified Dementia (chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), Unspecified Severity, without…

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

Based on observations, interviews, and records reviews, the facility failed to implement and follow their own established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility failed to follow their policy on smoking on 10/09/2024 when a red, labeled, self-enclosed, covered smoking receptacle in the designated smoking area was observed to contain plastic trash items and was lined with a clear, plastic trashcan liner. This failure could place residents at risk of injury, burns, and an unsafe smoking environment. The findings included: During an observation on 10/09/2024 at 9:45 a.m., the designated outside smoking area had a red, metal container, approximately four (4) feet tall, that had a round cover over the top. A silver side panel pushed inwards to allow cigarettes to be put inside. The metal container was labeled, Flammable Ash Only. When the panel was pushed inwards, a Cheez-it package, and an aluminum soda can were observed. When the lid and outside covering of the container was removed, the container was observed to be lined with a clear, plastic trash…

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 records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #10) of 3 residents reviewed for baseline care plans. The facility failed to ensure Resident #10 had a baseline care plan developed within 48-hours after admission with goals, services, and interventions. This failure could place newly admitted residents at risk of not receiving the care and services needed to promote good health and continuity of services. The findings included: Record review of Resident #10's Facesheet, dated 10/15/2024, revealed Resident #10 was a [AGE] year-old female, with an admission date of 06/11/2024. Diagnoses included Hypothyroidism (underactive thyroid), Depression (mood disorder that can affect how a person feels, thinks, and behaves), Insomnia (trouble falling asleep), and Essential hypertension…

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 records reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #3) of 3 residents reviewed for care plan revision. Resident #3's comprehensive care plan was not reviewed or revised after Resident #3 fell and sustained a lower, left leg fracture. This failure could place residents at risk for inadequate care. The findings included: Record review of Resident #3's Facesheet, dated 10/10/2024, revealed Resident #3 was an [AGE] year-old female, with an admission date into the facility of 05/30/2024. Diagnoses included Unspecified Dementia (chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning) and Unspecified Severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety). Record review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #3'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 interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 7 of 7 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings in August 2023, October 2023, November 2023, December 2023, April 2024, May 2024, and June 2024. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of sign in sheets for QAPI meetings in October 2023, November 2023, April 2024, May 2024, and June 2024 revealed no evidence that the MD attended QAPI meeting. During an interview on 07/30/2024 at 10:45a.m., the ADMN stated he was missing MD's signature on some of the QAPI meeting sign in sheets. He stated the MD does not attend the meetings in person or by phone and the ADMN would take the sign in sheets to MDs office after the meeting for signature. He stated he would go over the meeting…

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 treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 15 residents (Resident # 6 and Resident #18) reviewed for dignity. The facility failed to ensure staff treated Resident #6 and # 18 with dignity while assisting residents with their lunch meal. This failure could place residents at risk of a diminished quality of life and lead to loss of self-esteem, isolation, and weight loss. The findings included: Record review Resident #6's electronic face sheet dated 07/31/2024 revealed: a [AGE] year-old female admitted on [DATE] with the following diagnosies: Pressure Ulcer of right buttock stage II, Pressure ulcer of right heel stage III, chronic kidney disease stage 4 (severe stage of kidney damage), Chronic Pain, Essential Hypertension (high blood pressure), Unspecified Dementia, Encephalopathy (brain disease that alters brain function)…

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 develop and implement a comprehensive person- centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 15 residents (Resident #16, #17, #19, #24) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #16's Care plan incorporated Code status and PASRR status. The facility failed to ensure Resident #17's Care Plan incorporated measurable objectives or interventions for Tracheostomy Care or Feeding Tube. The facility failed to ensure Resident #19's Care plan incorporated interventions for falls. The facility failed to ensure Resident #24's Care Plan was updated after use of Bactrim (antibiotic) and UTI was resolved. This failure could place the residents at risk for decreased quality of life and not having their needs met. The findings…

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 environment that was as free from accident hazards as was possible for 2 of 3 (Back Hall and Front Hall) halls reviewed for accident hazards . The facility failed to ensure shampoo, wound cleanser, nail polish remover, shaving cream, disinfectant spray, and perineal and skin cleanser were locked in the Back Hall Shower room and not accessible to residents. The facility failed to ensure perineal and skin cleanser were locked in the Back Hall bathroom room and not accessible to residents. The facility failed to ensure bottle of shampoo was locked in the front hall bathroom and not accessible to the residents. These failures could place residents at risk of injury due to hazardous chemicals. Findings include: During an observation on [DATE] at 9:56 AM, the Back Hall Shower room door was propped open with a 1-gallon bottle of shampoo, there was a half of a 1-gallon bottle of perineal and skin cleanser, and cabinet that 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 observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 3 of 14 resident (Resident #2, Resident #14, and Resident #235's) reviewed for oxygen administration. The facility failed to ensure an Oxygen in Use sign was posted on the outside of Resident #2, Resident #14, and Resident #235's door. These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection. The findings include: Record review of Resident # 2's face sheet dated 07/31/2024 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), muscle wasting and atrophy (loss or thinning of your muscle tissue), and muscle weakness. Record review of…

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

Based on interview and record review the facility failed to ensure 3 (NA B, NA C, and NA D) of 10 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA B, NA C, and NA D were certified within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known. Findings include: Review of facilities employee files revealed: -NA B had a hire date of 1/30/2024 and worked full time, -NA C had a hire date of 9/15/2023 and worked full time, and -NA D had a hire date of 3/15/2024 and worked full time. During an interview on 07/31/2024 at 10:18 a.m., NA B stated he had been working at the facility since January. He stated that he had never been certified and was not attending training courses . During an interview on 07/31/2024 at 2:47 p.m., the DON stated that her expectation would be for the facility to have certified nurse assistants. She stated there had been no certified applicants and had only been…

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 menu was followed for 1 of 2 (Residents #235) residents who received a pureed meal reviewed during 2 of 2 lunch meals. The facility failed to ensure Resident #235, who received a pureed diet, was provided the food according to the menu, including a role on 07/29/2024 and mashed potatoes on 07/30/2024. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: Record review of Resident #235's face sheet dated 07/17/2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (heart disease that effects blood flow by clogged arteries that could cause chest pain, shortness of breath, fatigue and confusion among other symptoms), and anxiety. Record review of Resident #235's entry MDS dated [DATE] did not reveal cognitive assessment documented. Record review of Resident #235'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 observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that resident food was discarded when past expiration date. The facility failed to ensure ice scoops were stored covered. The facility failed to ensure items in refrigerator where food was stored were cleaned. The facility failed to ensure dinnerware was in good condition, without chips. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 07/29/24 at 9:45 AM of the kitchen revealed: 1. Two ice scoops were uncovered laying on the counter next to the ice machine. 2. An unopened bottle of buttermilk dated 7/16/24 in the refrigerator. 3. A tub contained 4 unopened bottles of wine, one bottle had spilled in the bucket, and there was a black substance in bottom of tub. 4. A chipped plate and chipped coffee cup were observed being served 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 observations, interviews and record reviews, 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 infection control procedures for 1 of 1 ice scoop reviewed for infection control. The facility failed to follow their Infection Control policy regarding CDC guidelines of performing hand hygiene when assisting residents with meals and one ice scoop laying on a counter in the kitchen not covered and one ice scoop laying on a cart uncovered at the nurses' station. This failure could place residents at risk of the spread of infections. Findings included: During an observation on 07/29/2024 at 09:45 AM, Ice scoop was laying on the counter in the kitchen not covered. During an observation on 07/29/2024 at 09:45 AM one ice scoop was laying on a cart beside ice chest at nurses' station. Ice scoop was not covered. During an interview on 07/29/2024 at 09:45 AM The DM stated the ice scoop…

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 conduct regular inspections of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 4 of 4 (Residents #2, #20, #30 and #235) residents reviewed for bed rails. The facility failed to assess bed rails for risk of entrapment for Residents #2, #20, #30 and #235's beds. This failure could place residents who have bed rails at risk for injury related to poor maintenance of the bed rails. The findings included: Resident #2 Record review of Resident # 2's face sheet dated 07/31/2024 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), muscle wasting and atrophy (loss or thinning of your muscle tissue), and muscle weakness. Record review of Resident #2's quarterly 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 observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 (Resident #19) of 15 residents reviewed for resident call system. The facility failed to provide a working communication system on 07/29/2024 that was easily at reach and that would allow Resident #19 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living. The findings included: Record review of Resident #19's face sheet dated 07/31/2024, revealed: an [AGE] year-old-male admitted on [DATE], with the following diagnosis blindness to the right and left eye, pulmonary embolism, Type 2 Diabetes, and dizziness. Record review of Resident #19's Annual MDS dated [DATE] revealed: Section B- Hearing, Speech, and Vision revealed Resident #19's vision was severely impaired (no vision or sees only light); Section C- Cognitive Patterns…

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 and implement written policies and procedures to prohibit and prevent abuse and neglect for 1 of 1 staff (NA B) reviewed for Resident Abuse . The facility failed to suspend staff named as AP or remove staff named as AP from direct care position during resident abuse investigation . This deficient practice could place residents at risk for abuse and neglect. The findings were: Record review of the Resident #20's face sheet dated 07/31/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness following stroke) and vascular dementia (memory deficit from blood flow issues). Record review of Resident #20's annual MDS dated [DATE] revealed: BIMS score of 07 which indicated severe cognitive impairment. Further review of the MDS Section E - Behavior revealed no hallucinations or delusions and did…

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 that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and prevent new ulcers from developing for 1 of 13 (Resident #20) residents reviewed for pressure ulcers. The facility failed to perform weekly skin assessments for Resident #20 who was assessed as being at risk for skin breakdown. These failures could place residents at risk of developing pressure ulcers, infections and worsening of wounds from delay in treatment. Findings include: Record review of the Resident #20's face sheet dated 07/31/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness following stroke), stage 2 pressure ulcer of other site (red…

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 mechanical and electrical equipment in a safe operating condition for 7 (Resident #1, #2, #3, #4, #5, #6, and #7) of 7 rooms affected by mechanical failure. 1. The facility failed to repair heating to resident's room to properly maintain safe and comfortable temperature for residents in their rooms. This failure could place residents at risk of cold room temperatures. Findings included: In an observation and interview on 12/13/23 at 1:40 pm, Resident #1 stated the facility informed him that the heating unit for his room was out and the facility offered for him to relocate to another room in the facility that had heating. Resident #1 stated he thought the room temperature was fine and declined to move. An observation of the room temperature at time of survey was comfortable at 74 degrees. In an observation and interview on 12/13/23 at 1:55 pm, Resident #2 stated she was informed of the problem with the heating and the facility offered to move her to another room. Resident #2 stated she was fine 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 accommodate residents needs and preferences and accommodation of needs, for 2 (Resident #2, Resident #5) of 5 residents reviewed for dignity. The facility failed to ensure Resident #2 and Resident #5 call lights were within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Review of Resident #2's face sheet dated 06/08/2023 revealed a [AGE] year-old female admitted on [DATE] with following diagnosis: Dementia, Anxiety disorder, Major Depressive disorder, Psychotic Disorder with Delusions and Alzheimer's. Review of Resident #2's MDS dated [DATE] revealed: Section C -Cognitive Patterns BIMS score of 00, which indicated she had severe cognitive impairment). Section F: Functional Status revealed Resident #2 required extensive assistance with transfers and when out of bed did not ambulate on her on was in wheelchair. Review of Resident #2's most…

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 manage the personal funds of the residents deposited with the facility for 2 (Residents #16 and Resident #29) of 12 residents reviewed with trust funds. The facility failed to ensure Residents #16 and Resident #29 had ready access to their personal funds on the weekends or if the BOM was not available. This failure could place residents whose funds are managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings included: 1. Record review of electronic face sheet indicated Resident #16 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included urinary tract infection, muscle weakness, and anemia (low blood level). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 had a BIMS score of 07, which indicated her cognition was moderately impaired. During an interview on 06/08/2023 at 3:49 PM, Resident #16…

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 physician signed and dated all orders for 3 of 12 residents (Residents #14, #24, and #88) reviewed for complete and accurate medical records. The facility failed to obtain orders for bed rails for Residents #14, #24, and #88. This failure placed resident at risk for not receiving the appropriate physician ordered care. Findings Included: Record Review of the Resident #14's Face Sheet dated 06/08/2023, revealed she was a 91 yr. old Female, admitted to the facility on [DATE], with a diagnoses of Congestive heart Failure, open wounds, and skin conditions. Record Review of Resident #14's MDS, dated [DATE], Section C revealed a BIMS score of 09 (moderately impaired). Record Review of Resident #14's undated Care Plan, revealed, SIDE RAILS: (half rails) up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition (every 2 hours) and as necessary to avoid iinjury. 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.

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 7 days of the FY 1 Quarter out of 4 Quarters. (11/05/2022, 11/06/2022, 11/12/2022, 11/13/2022, 12/03/2022, 12/04/2022, and 12/17/202) This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record Review of facility's PBJ RN coverage report for FY Quarter #1 of 4 revealed: Days with no RN coverage: 11/05/2022, 11/06/2022, 11/12/2022, 11/13/2022, 12/03/2022, 12/04/2022, and 12/17/2022 In an interview on 06/08/2023 at 6:00 PM, the Admn stated her expectation was an RN to 8 hours a day 7 days week. She stated it was the Admn's responsibility 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 observations, interviews, and record review, the facility failed to store medications in a locked compartment for 1 of 2 (Medication Cart 1) reviewed for medication storage. The facility failed to keep medication cart 1 secured when not in use, leaving resident medication in a locked compartment when not being immediately used. The failure placed residents at risk of adverse actions caused by inadvertent medication consumption as well as drug diversion. Findings included: During an observation on 06/05/2023 at3:04 PM, the medication cart 1 was unlocked by RN-Q being left in the hallway facing outward toward the open hallway, while administering medications in a resident's room. During an interview on 06/05/2023 at 3:05 PM, RN-Q stated she was the nurse in charge with the cart being hers. She stated the cart contained OTC drugs, heart disease medication, BP medications, diabetes medications, ALZ medications, with narcotics being left under one lock and not two which she knew was in the facility policy. During an interview on 06/05/2023 at 03:25 PMRN-Q stated the negative…

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

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation on 06/05/2023 between 10:00 AM and 11:15 AM revealed: Refrigerator 1. One opened bag of grated cheese with out an open date. 2. One opened package of brown sugar not sealed, exposed to air. 3. One opened package of ham without an open date. 4. One opened package of turkey without an open date. 5. One opened package of sliced cheese without an open date. Cook R was cutting pie without gloved hands and had whipped topping on his hands. During an interview on 06/05/2023 at 2:30 PM the DM stated her expectation was that staff wear gloves while…

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 maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 8 of 8 meetings (May 2022, July 2022, August 2022, September 2022, October 2022, December 2022, February 2023, and April 2023) reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings in May 2022, July 2022, August 2022, September 2022, October 2022, December 2022, February 2023, and April 2023. The facility did not ensure the DON, or a representative attended QAPI meetings in July 2022, August 2022, and February 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets for May 2022, July 2022, August 2022, September 2022, October 2022, December 2022, February 2023, and April 2023 indicated the MD or a representative did not sign in for the meetings. 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.

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 1 of 3 (RN-Q) staff observed during medication administration. RN-Q placed her fingers inside the medication cup and the crushed the medication sleeve while preparing medication and without performing hand hygiene while administering medication. RN-Q did not sanitize the glucometer before or after use on a resident. RN-Q did not place lancet in the sharps box after use it on a resident. These failures placed residents of the facility at risk of infections from medication administration. Findings included: In an observation on 06/05/2023 at 3:30 PM of medication administration with RN-Q, she touched the inside of the medication cup with her bare hand touching the medication. After administering medication to the resident, RN-Q did not perform hand hygiene before continuing to prepare other…

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.