Monument Healthcare American Fork

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 5 of 47 sampled residents, that the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, two residents did not receive showers as requested or as scheduled. In addition, residents were not provided assistance with nail care or dining. Resident identifiers: 15, 27, 30, 36, and 51. Findings Included: 1. Resident 27 was admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes, anxiety disorder, major depressive disorder, obstructive sleep apnea, and vascular dementia. On 11/27/23 at 11:22 AM, an interview was conducted with resident 27's family member. Resident 27's family member stated resident 27 was showered only when staff were able to. Resident 27's family member stated…

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, it was determined that the facility failed to provide sufficient staffing to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, it was determined that the facility did not provide sufficient nursing staff to meet the resident's needs in the areas of answering resident call lights in a timely manner; obtaining resident weights; or assisting the residents with their bathing. Resident Identifiers: 9, 30, 39, 53, 63, and 64. Findings include: RESIDENT INTERVIEWS 1. On 11/27/23 at 11:33 AM, an interview was conducted with resident 9. Resident 9 stated that the CNA's get upset with her when she gets up on her own and they tell her to use…

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 it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 11/29/23 at 11:50 AM, an interview was conducted with the facility DM. The DM stated that he started his Certified Dietary Manager (CDM) course a month ago, after he was promoted to the DM position. The DM stated that he was employed as a cook prior to the promotion. The DM stated that there was a corporate CDM and Registered Dietitian (RD) that were in the facility, but that they were onsite only once a week.

Based on interview and record review, the facility did not ensure that the menus were followed. Specifically, residents who were prescribed a fortified diet, were not provided with the appropriate foods. Findings include: On 11/29/23 at 2:20 PM, the facility Dietary Manager (DM) provided a list of residents receiving a fortified diet to surveyors. The DM also provided a spreadsheet of the menu for residents receiving a fortified diet. The DM was asked how he fortified the milk that was provided to residents. The DM stated that he was using whole milk as the fortified milk. The DM stated that he used to add fortified milk powder to 2% milk but that the most recent manager before him told him to just use whole milk instead. When asked about alternate meals, the DM stated that there were not alternate menu items prepared in advance, and that if we have extra chicken, we just say let's make an extra chicken dish. On 12/4/23 at 1:47 PM, an interview was conducted with [NAME] 1. [NAME] 1 stated she was prepping food for dinner. [NAME] 1 stated she did not know what a fortified diet 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.

Based on observation, interview and record review it was determined, for 9 of 47 sampled residents, that the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, a test tray was bland and resident council minutes revealed complaints of food quality. Resident identifiers: 9, 10, 15, 17, 18, 32, 36, 39 and 64. Findings include: Interviews: 1. On 11/28/23 at 9:42 AM, an interview was conducted with resident 39. Resident 39 stated she lost 40 pounds because she cant eat this food. Resident 39 stated the food did not look good. Resident 39 stated the food was cold, there was no flavor and the food was the same thing everyday. Resident 39 stated she was served rotten lettuce and pears. Resident 39 stated she asked staff how do you expect us to eat this?. 2. On 11/27/23 at 11:18 AM, an interview was conducted with resident 18. Resident 18 stated she did not get any snacks of any kind and was not offered snacks after dinner. 3. On 11/28/23 at 9:28 AM, an interview was conducted with…

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

Based on observation, interview and record review, the facility did not ensure that food was prepared in a form designed to meet individual needs. Specifically, pureed foods were not prepared appropriately. Resident identifier: 36. Findings include: 1. On 11/27/23 at 10:41 AM, an interview was conducted with resident 36. Resident 36 stated he was on a pureed diet and the food taste did not taste good. 2. On 11/29/23 at 12:35 PM, a sample tray was requested from the facility. The tray was placed in the last cart to be passed to residents. After all residents had been served from the cart, as of 12:51 PM, the sample tray was observed and temperatures were taken. The pureed meal served was ground beef, refried beans, zucchini, and a pumpkin dessert. All of the items were brown. The pureed meat was 110 degrees Fahrenheit (F), and had a watery taste. The meat did not have any flavor and was bland. The zucchini was 96 degrees F, and had watery consistency instead of the appropriate pureed consistency. The pureed zucchini had run into the beans and meat on the plate. The pureed refried…

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 observation, the facility did not serve food that accommodated resident preferences. Specifically, three residents were provided meals that were inconsistent with their requests. Resident identifiers: 28, 60 and 123. Findings include: On 11/29/23, an observation was made of the lunch meal. The following observations were made: a. Resident 60's meal ticket was observed. The meal ticket indicated that resident 60 had requested a double cheeseburger as an alternate, but was served the regular meal of a taco with beans. b. Resident 123's meal ticket was observed. The meal ticket indicated that resident 123 had requested a cheeseburger as an alternate, but was served the regular meal of a taco with beans. c. Resident 28's meal ticket was observed. The meal ticket indicated that resident 28 was to receive fortified milk and a banana. The resident received a regular milk, and no banana. On 11/29/23 at 2:20 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that there were alternates that the residents could choose from if they did not want…

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 observation, the facility did not provide a nourishing snack at bedtime or upon request. Resident identifiers: 10, 18, 32 and 39. Findings include: 1. On 11/28/23 at 9:42 AM, an interview was conducted with resident 39. Resident 39 stated she was not offered snacks between meals or at bedtime. 2. On 11/27/23 at 11:18 AM, an interview was conducted with resident 18. Resident 18 stated she did not get any snacks of any kind and was not offered snacks after dinner. 3. On 11/27/23 at 2:23 PM, an interview was conducted with resident 32. Resident 32 stated sometimes there was not enough food. 4. On 11/28/23 at 10:32 AM, an interview was conducted with resident 10. Resident 10 stated he did not receive snacks at night. 5. On 11/27/23, a staff member was observed in the hallway by the kitchen talking to another staff member. The staff members stated that there were no snacks available on the evening of 11/25/23, which was a Saturday. On 12/6/23 at approximately 10:00 AM, an interview was conducted with Certified Nursing Assistant (CNA)CNA 4. CNA 4 stated that snacks…

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 observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, cross contamination was observed during the trayline process. Findings include: 1. On 11/29/23 the trayline process for the lunch meal was observed. The following observations were made: a. At 12:24 PM, [NAME] 2 was observed to touch his glasses and then pick up silverware and place it on a tray. [NAME] 2 was then observed to place his fingers on the inside of a dessert cup as he picked up the cup to place it on a resident tray. b. At 12:27 PM, [NAME] 2 was observed to touch his face and then continue to place silverware and other items on resident trays. c. At 12:28 PM, [NAME] 2 was observed to touch his pants, glasses, and apron before touching silverware and other items for resident trays. d. At 12:30 PM, [NAME] 2 was observed to touch his glasses, and then place covers on resident plates, touch silverware, and cups of dessert. 2. On 12/6/23 at 9:05 AM, an observation was made in the Secured Unit. There…

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 did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include both the number of residents and facility's resident capacity; the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population; the staff competencies that were necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services, and other physical plan considerations that were necessary to care for this population; and any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including but not limited to, activities and food and nutrition services. Specifically, the facility did not have an accurate facility assessment that included all 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 observation and interview, it was determined that the facility failed to ensure that all corridors were equipped with firmly secured handrails. Specifically, four handrails throughout the facility were found to be loose which created a resident safety hazard. Findings included: An initial facility tour was conducted on 11/30/23 at 1:44 PM. Loose handrail was observed in the following corridors: 1. Outside of the maintenance door. 2. Outside of room [ROOM NUMBER]. 3. Two doors down from the entrance of the main activity room. 4. Outside of room [ROOM NUMBER]. On 12/5/23 at 11:09 AM, a facility walk through was completed with Regional Plant Operations 1. Regional Plan Operations 1 observed the loose handrails. On 12/5/23 at 11:09 AM, an interview was conducted with Regional Plant Operations 1. Regional Plant Operations 1 stated that he had probably not seen anything that needed repair because the facilities maintenance staff was no longer employed at the facility as of 11/30/23.

Based on interview and record review, the facility did not provide training to their nurse aides that was sufficient ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; include dementia management training and resident abuse prevention training; address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff; and address the care of the cognitively impaired. Findings include: On 12/6/23 at 4:33 PM, an interview was conducted with Administrator (ADM) 2. ADM 2 stated nurse aide training was completed through a computer application. ADM 2 stated they would need to send the training information. No additional information was provided regarding Nurse Aide training the facility provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 47 sampled residents, that the facility failed to provide residents the right to participate in the development and implementation of a person-centered plan of care, the right to attend meetings regarding the person-centered plan of care, and the right to request revisions to the person-centered plan of care. Specifically, a resident representative was not informed or included in care planning meetings in which concerns regarding the resident's plan of care could be discussed. Resident identifier: 22. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses which included dementia, moderate intellectual disabilities, atherosclerotic heart disease, asthma, and hypertension. On 11/28/23 at 10:24 AM, an interview was conducted with a Family Member (FM). The FM stated she did not know about meetings where her family member's plan of care would be discussed and had never been asked to join any meetings. The FM stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 47 sampled residents, that the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, a resident was observed to have medications on the bedside table in a medication cup and was not evaluated to determine if they were safe to self administer medications. Resident identifier: 9 Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included dementia, cognitive communication deficit, bipolar disorder, anxiety disorder, and schizoaffective disorder. On 11/27/23 at 11:33 AM, an observation was made of resident 9's room. There were multiple medications observed in the medication cup on the breakfast tray located on resident 9's bedside table. Resident 9 was interviewed and stated there she had just woken up and had not see the medication cup. Resident 9 stated that she would often wake up 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, it was determined, for 1 of 47 sampled residents, that the facility failed to promote and facilitate self-determination through support of resident choice, including the right to make choices about aspects of their life in the facility that were significant to the resident. Specifically, a resident was not assisted in obtaining services to get their hair done. Resident identifier: 57. Findings included: Resident 57 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, delusional disorders, type 2 diabetes, myocardial infarction, congestive heart failure, hypertension, leukemia, dementia, and hypothyroidism. On 11/27/23 at 10:56 AM, an interview was conducted with resident 57 in the dining room. Resident 57 stated that she wanted to get her hair straightened, but the facility could not do her hair. Resident 57 further stated she had asked the nurses, but they did not help. An observation was made of resident 57. Resident 57 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 47 sampled residents, that the facility did not ensure each resident had the right to manage his or her financial affairs. Specifically, there was no system for staff to track how a resident with dementia's money was spent. Resident identifier: 43. Findings include: Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis of left lower limb, collapsed vertebra, major depressive disorder and dementia. On 12/6/23 at 12:04 PM, an observation was made of resident 43 and the Activities Director (AD). Resident 43 was yelling that his bank card had been taken and was being used. Resident 43 stated that his bank account had charges that were not from him and he was being ripped off. Resident 43 stated he got hammered for 500 to 600 dollars this month. Resident 43 stated to the AD that he was charged for too many cartons of cigarettes that month. The AD was observed to raise her voice and tell…

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 did not provide individual financial records through quarterly statements for 1 of 47 sample residents who had entrusted the facility with their personal funds. Resident identifier: 18. Findings include: Resident 18 was admitted to the facility on [DATE] with diagnoses that included hypertension, viral hepatitis C, history of transient ischemic attack, and hyperlipidemia. On 11/27/28 at 11:18 AM, an interview was conducted with resident 18. Resident 18 stated that she had a personal funds account with the facility but that she did not receive statements to let her know how much money she had in her account. On 12/5/23, the Business Office Manager (BOM) confirmed that resident 18 had a personal funds account with the facility, and provided surveyors with a statement of resident 18's transaction history of the previous 6 months. On 12/6/23, an interview was conducted with the BOM regarding the process of personal funds accounting. The BOM stated that he had a…

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

Based on interview, the facility did not send a copy of resident 30-day discharge notices or hospitalizations to the Long-Term Care Ombudsman. Findings include: On 11/27/23 an interview was conducted with Administrator (ADM) 1. ADM 1 stated that the Social Worker (SW) was in charge of sending a monthly list to the ombudsman (OMB) of residents who had been hospitalized and/or given a 30 day discharge notice. On 11/29/23 at 8:30 AM, an interview was conducted with the facility SW. The facility SW stated that he was in charge of keeping a log of residents who had been discharged from the facility. The SW stated that he had not been sending a monthly list to the ombudsman of residents who had been hospitalized and/or given a 30 day discharge notice. The SW stated that it was brought up a month ago in a facility staff meeting because it wasn't being done, but no one was put in charge of it, and there was no plan. The SW stated that the county ombudsman had not asked him for the list. On 11/28/23, OMB 1 arrived at the facility. OMB 1 stated that she had not been receiving a monthly list…

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 it was determined, for 1 of 47 sampled residents, that the facility did not develop and implement a baseline care plan within 48 hours of admission. Specifically, there were no baseline care plan created for a resident that was admitted for respite stay. Resident identifier: 121. Findings include. Resident 121 was admitted to the facility on [DATE] and discharged on 7/8/23 with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. Resident 121's medical record was reviewed 12/4/23 through 12/6/23. There were no baseline care plans located in resident 121's medical record. Additional information was requestef for care plan on 12/12/23. Care plans provided were initaited on 12/12/23. It should be note that resident 121 discharged [DATE]. On 12/6/23 at 2:23 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that nursing…

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 did not develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Specifically, a resident was not provided with assistance with relocation to a different facility despite multiple requests. Resident identifier: 8. Findings include: Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy, acute kidney failure, acute respiratory failure, chronic heart failure, major depressive disorder, muscle weakness, chronic viral hepatitis C, and protein calorie malnutrition. On 11/28/23 at 11:50 AM, an interview was conducted with resident 8. Resident 8 stated that I've been trying to get out of here for 4 years. Resident 8 stated that the social workers here just wait until their next job…

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 it was determined, for 1 of 47 sampled residents, that the facility did not provide the necessary care and services to ensure that activities of daily living that included hygiene: bathing, dressing, grooming, and oral care, were carried out to maximize the resident's functional abilities. Specifically, a resident was not provided oral care, assistance in using corrective lenses or ensuring the resident was wearing shoes. Resident identifier: 22 Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses which included dementia, moderate intellectual disabilities, atherosclerotic heart disease, asthma, and hypertension. 1. On 11/28/23 at 10:24 AM, it was observed that resident 22 had multiple teeth that were broken, light brown, and had a yellow substance along the border of her gums and in the crevices between her teeth. Resident 22's medical record was reviewed 11/27/23 through 12/6/23. The Quarterly Minimum Data Set (MDS) dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 47 sampled residents, that the facility did not ensure a resident received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident with a positive urinary tract infection did not receive timely results for a urinalysis and a culture and sensitivity. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with diagnoses which included Parkinson disease, urinary tract obstruction, and dementia. On 12/4/23 at 1:10 PM an interview was conducted with resident 17. Resident 17 stated that he was frequently on antibiotics for infections with his superpubic catheter. Resident 17's medical record was reviewed 11/27/23 through 12/6/23. A care plan dated 12/12/22, documented a focus that resident 17 has a super pubic catheter: r/t [related to] bph [benign prostatic hyperplasia]. Interventions included: a. the resident has 16 indwelling. position catheter bag and tubing below 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 it was determined, for 1 of 47 sampled residents, that the facility did not provide routine and emergency drugs and biological's to its residents. Specifically, a resident was not administered medications as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 21 Findings Included: Resident 21 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included hypertensive chronic kidney disease with stage 5 chronic kidney disease, schizoaffective type, type 2 diabetes mellitus, diastolic congestive heart failure and cognitive communication deficit. Resident 21's medical record was reviewed on 11/30/23. On 11/5/23 at 11:40 AM, an order administration note stated, Renvela Oral Packet 0.8 GM . Give 3 packet by mouth before meals every Mon [Monday], Tue [Tuesday], Wed [Wednesday], Thu [Thursday], Fri [Friday], Sat [Saturday], Sun [Sunday] related to hypertensive chronic kidney disease with stage 5 chronic 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 interview and record review it was determined, for 1 of 47 sampled residents, that the facility did not ensure that a resident who received psychotropic drugs were not given these drugs unless the medication was to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was prescribed a psychotropic medication with an off label use and with out adequate monitoring. Resident identifier: 170. Findings include: Resident 170 was admitted to the facility on [DATE] with diagnosis which included subarachnoid hemorrhage, acute respiratory failure, encephalopathy, seizures. Resident 170's medical record was review 11/27/23 through 12/6/23. An admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. A physician order dated 11/6/23, Quetiapine Fumarate oral tablet 25 MG [milligrams], give 1 tablet at bedtime for sleep. [It should be noted quetiapine was an antipsychotic,…

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 it was determined, for 2 of 47 sampled resident, the facility did not ensure residents were free of any significant medication errors. Specifically, a dialysis resident was not administered their Renvela oral packet which was a phosphate binder as ordered by the physician. In addition, another resident was not administered their appropriate medications. Resident Identifiers: 21 and 121. Findings include: 1. Resident 21 was admitted on [DATE] and readmitted on [DATE] with the following diagnosis which included hypertensive chronic kidney disease with stage 5 chronic kidney disease, schizoaffective type, type 2 diabetes mellitus, diastolic congestive heart failure and cognitive communication deficit. Resident 21's medical record was reviewed on 11/30/23. On 11/5/23 at 11:40 AM, an order administration note stated, Renvela Oral Packet 0.8 GM . Give 3 packet by mouth before meals every Mon [Monday], Tue [Tuesday], Wed [Wednesday], Thu [Thursday], Fri [Friday], Sat [Saturday], Sun…

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, for 2 of 47 sampled residents, the facility did not obtain laboratory services only when ordered by a physician. Specifically, resident's had laboratory services completed without a physician's order. Resident identifier: 36 and 121. Findings include: 1. Resident 121 was admitted to the facility 7/1/23 and discharged on 7/8/23 with diagnoses which included congestive heart failure, chronic kidney disease, monoclonal gammopathy, transient cerebral ischemic attack, pulmonary fibrosis, and respiratory disorder. Resident 121's medical record was reviewed 12/3/23 through 12/6/23. A progress note dated 7/7/23 at 9:43 AM, Called [name removed and phone number] with urine sample for [name of lab] to process. Hospice company. There was no physician's order or results located in resident 121's medical record. On 12/6/23 at 4:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she needed to call the hospice company to get the urine analysis (UA)…

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 it was determined, for 2 of 47 sampled resident, that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, residents with urinary tract infections were started on an antibiotic without Culture and Sensitivity results. Resident identifiers: 27 and 39. Findings Included: 1. Resident 27 was admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes, anxiety disorder, major depressive disorder, obstructive sleep apnea, and vascular dementia. Resident 27's medical record was reviewed 11/29/23 to 12/6/23. On 11/28/23 at 4:16 PM, a nurse note stated, regarding recent multiple falls. contusion/ bruising to the right side of forehead continues to heal routinely. bruising turning from purple to yellowish in color. Md [medical doctor] orders to collect ua [urinalysis] with c&s [culture and sensitivity] as indicated . 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 interview and record review it was determined that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 3 out of 32 sampled residents, medications were not administered as ordered by the physician due to not being available by the pharmacy. Resident identifiers: 111, 112, and 113. Findings included: 1. Resident 112 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to Parkinson's disease, diabetes mellitus type 2, end stage renal disease, protein-calorie malnutrition, reduced mobility, combined systolic and diastolic congestive heart failure, edema, essential primary hypertension, paroxysmal atrial fibrillation, and dependence on renal dialysis. Resident 112's medical record was reviewed on 2/23/22. On 2/10/22 at 2:31 PM, a Nursing Note documented that resident 112 was admitted from the local hospital. On 2/10/22 at 10:02 PM, an Orders - Administration Note documented amiodarone tablet 200…

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, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility's communal resident refrigerator contained items without proper labeling, and the resident communal snack refrigerator was maintained at a temperature higher than recommended standards. Findings included: On 2/24/22 at 10:21 AM, Licensed Practical Nurse (LPN) 2 was interviewed about the location of resident communal refrigerators. LPN 2 stated near the nurses' station there was a small refrigerator for resident snacks supplied by the kitchen, and there was also a larger refrigerator in the employee break room which would be used for resident food. LPN 2 stated the refrigerator in the break room was for resident and employee food. LPN 2 stated there was also a small refrigerator at the nurses station of the Memory Care unit which could be used for resident food. On 2/24/22 at 10:22 AM, the resident communal snack refrigerator was examined. The refrigerator had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility did not 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. Specifically, staff were observed without eye protection while working with residents on the Coronavirus Disease-2019 (COVID-19) unit, staff were observed to have dropped medications on the top of the medicine cart, staff picked up mediation with a bare hand and administered medications to a resident, and staff did not clean the end of an insulin pen prior to applying the needle for administration. Resident identifiers: 7 Findings included: 1. On 2/24/22 at 9:15 AM, an observation was made of Licensed Practical Nurse (LPN) 4. LPN 4 dropped a medication capsule on top of the medication cart then picked up the capsule with an ungloved right hand after touching the medication cart, medication cup, and medication cards…

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 it was determined that the facility did not provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, for 2 out of 32 sampled residents, a resident did not receive written notice prior to receiving a new roommate and a resident did not receive written notice prior to the room change. Resident identifiers: 12 and 112. Findings included: 1. Resident 112 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to Parkinson's disease, diabetes mellitus type 2, end stage renal disease, protein-calorie malnutrition, reduced mobility, combined systolic and diastolic congestive heart failure, edema, essential primary hypertension, paroxysmal atrial fibrillation, and dependence on renal dialysis. On 2/22/22 at 3:27 PM, an interview was conducted with resident 112. Resident 112 stated he was moved to a different room because he had issues with his…

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 it was determined the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility and to other officials. Specifically, for 1 out of 32 sampled residents, an incident of employee to resident sexual abuse was not reported to the State Survey Agency or Adult Protective Services (APS) no later than 2 hours after the allegation was made. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included but not limited to traumatic brain injury with loss of consciousness, chronic pain syndrome, functional quadriplegia, dysphagia, post-traumatic stress disorder, Coronavirus Disease-2019, muscle weakness, difficulty in walking,…

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 it was determined the facility did not develop and implement comprehensive person-centered care plans for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 2 out of 32 sampled residents, the facility did not demonstrate implementation of care plan interventions related to a resident's incontinence, did not develop interventions within a resident's potential skin integrity impairment care plan, and did not update a resident's care plan related to the resident's nutrition risk. Resident identifiers: 51 and 167. Findings included: 1. Resident 167 was admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, Coronavirus Disease-2019 (COVID-19), unspecified dementia, dehydration, retention of urine, muscle weakness, chronic kidney disease…

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 it was determined that the facility did not ensure that a resident's discharge summary was complete. Specifically, for 1 out of 32 sampled residents, the resident's discharge summary did not include a recapitulation of the resident's stay, the final summary of the resident's status at discharge, a reconciliation of all medications, or a post-discharge plan of care. Resident identifier: 32. Findings include: Resident 32 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included necrotizing fasciitis, venous insufficiency, collapsed vertebra, morbid obesity, major depressive disorder, cellulitis, cognitive communication deficit, essential hypertension, and sleep apnea. On 2/22/22, resident 32's medical record was reviewed. Physician's orders from 2/14/22, revealed resident 32 discharged from the facility on 2/14/22. On 2/14/22 at 11:33 AM, the Discharge Summary revealed resident 32 was discharged to another assisted living facility.…

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 it was determined the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 32 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 51. Findings included: Resident 51 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses which included acute respiratory failure, history of Coronavirus 2019 (COVID-19), muscle weakness, type 2 diabetes, vascular dementia, protein calorie malnutrition, hypokalemia, pneumonia, sepsis, anxiety, and need for assistance with personal care. On 2/22/22 at 7:55 AM, an observation of resident 51 was conducted. Resident 51 was observed to be sitting up in bed with the breakfast tray on the bedside table in front of resident 51.…

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 it was determined the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 32 sampled residents, the facility did not administer hypertensive medications when the blood pressure measurements were outside of the physician ordered parameters. Resident identifier: 22. Findings included: Resident 22 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease, acute and chronic respiratory failure, congestive heart failure, type 2 diabetes, bacteremia, dependence on renal dialysis, depressive disorder and essential hypertension. On 2/22/22,…

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 did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance at a harm level with F677, which was cited within the facility's 2019 recertification survey. Also, the facility was found to be in non-compliance with F883, which was cited within an abbreviated, complaint survey completed on 2/9/21. Resident identifiers: 167. Findings included: An annual recertification survey was completed on 12/5/19. During the survey deficiencies F550, F600, F677, F745, F761, F770, F842, and F849 were cited. An abbreviated, focused infection control survey was completed on 2/9/21. During the survey deficiency F883 was cited. An annual recertification survey was completed on 5/20/21. During the survey deficiencies F677 and F883 were identified as repeat deficiencies. 1. Based on observation, interview and record review, it was determined the facility did not ensure a resident who was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility did not ensure that each resident's medical record included documentation that indicated the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations. Specifically, for 1 out of 32 sampled residents, the medical record did not include documentation that information or education was provided regarding the benefits, risks, and potential side effects of the influenza and pneumococcal immunizations. In addition, the medical record did not included the administration or the refusal of the immunizations. Resident identifier: 47. Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which included but not limited to Coronavirus Disease-2019 (COVID-19), pneumonia due to coronavirus disease 2019, acute respiratory failure with hypoxia, muscle weakness, difficulty in walking, shortness of breath, and pain. Resident 47's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility did not ensure all mechanical, electrical, and patient care equipment were kept in safe operating condition. Specifically, the facility was unable to ensure a resident had a functioning bed while at the facility. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, Coronavirus Disease-2019 (COVID-19), major depressive disorder, polycystic ovarian syndrome, hypertension, abnormalities of gait and mobility, history of falling, morbid obesity, congestive heart failure, idiopathic aseptic necrosis of the pelvis, fracture of the upper end of the right tibia, hypothyroidism, protein-calorie malnutrition, muscle weakness, and type 2 diabetes mellitus. On 2/23/22 08:46 AM, resident 2 was interviewed. Resident 2 stated their bed would not raise higher than several inches above the ground, and it had started to give her slight pain in her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility did not ensure that resident rooms were designed and equipped for adequate nursing care, comfort, and privacy of resident. Specifically, for 1 out of 32 sampled residents, the staff were storing the residents walker and wheelchair in the hallway outside of the residents room when they were not in use. Resident identifier: 113. Findings included: Resident 113 was admitted to the facility on [DATE] with diagnoses which included but not limited to Coronavirus Disease-2019, orthopedic aftercare, displaced comminuted fracture of left patella, difficulty in walking, muscle weakness, history of falling, chronic viral hepatitis C, diabetes mellitus type 2, schizoaffective disorder bipolar type, major depressive disorder, borderline personality disorder, and asthma. On 2/22/22 at 11:39 AM, an interview was conducted with resident 113. Resident 113 stated it was very difficult for her to maneuver the walker into the bathroom and use the toilet. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility did not ensure that a single resident room measured at least 100 square feet. Specifically, for 1 out of 32 sampled residents, the resident's usable living space of the room measured under 100 square feet. Resident identifier: 113. Findings included: Resident 113 was admitted to the facility on [DATE] with diagnoses which included but not limited to Coronavirus Disease-2019, orthopedic aftercare, displaced comminuted fracture of left patella, difficulty in walking, muscle weakness, history of falling, chronic viral hepatitis C, diabetes mellitus type 2, schizoaffective disorder bipolar type, major depressive disorder, borderline personality disorder, and asthma. On 2/22/22 at 11:39 AM, an observation was conducted of resident 113's room. Resident 113 was standing next to the side her bed and was observed leaning against her bed side table which was pushed up against the adjacent wall. An interview was conducted with resident 113. Resident 113…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility did not ensure that a resident bedroom had at least one window to the outside. Specifically, for 1 out of 32 sampled residents, a resident bedroom did not have a window to the outside. The window was located within the resident bathroom and was unable to be seen from the resident bed. Resident identifier: 113. Findings included: Resident 113 was admitted to the facility on [DATE] with diagnoses which included but not limited to Coronavirus Disease-2019, orthopedic aftercare, displaced comminuted fracture of left patella, difficulty in walking, muscle weakness, history of falling, chronic viral hepatitis C, diabetes mellitus type 2, schizoaffective disorder bipolar type, major depressive disorder, borderline personality disorder, and asthma. On 2/22/22 at 11:39 AM, an observation was conducted of resident 113's room. Resident 113's room was observed to not have a window to the outside. The window was observed in resident 113's bathroom and resident…

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