Monroe Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an effective pest control program on three of three resident units and in the main kitchen and common areas of the facility. The findings included:On 8/19/25 at 1:55 p.m., a review of resident council minutes revealed that on 7/7/25, the resident council reported that Residents are seeing gnats and roaches. Both residents listed on the grievance lived on the 200 South unit. During the resident council meeting held Dec. 18, 2024, it noted . The group all mentioned an increase in cockroach sightings. In the September 2024 meeting it noted, . Resident [name redacted] stated he spotted a cockroach in his room by his bed recently. During the August 2024 resident council meeting, notes included, . Cockroaches have recently been spotted in [three resident's names redacted] and in the phone booth. Group stated that all has already been reported. On March 20, 2024, during…

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

Based on observations, resident interview, staff interview, clinical record review, and facility documentation review the facility staff failed to assess a resident's ability to safely self-administer medications for one resident, Resident #9 (R9) out of a survey sample of 18 residents. The findings included:Facility staff allowed R9 to keep medication at the bedside for self-administration without completing a self-administration assessment.On 8/19/25 at 11:10 a.m., an observation was conducted of medications at R9's bedside. At that time, an inhaler, CBD pain ointment, menthol pain ointment, and vitamin D3 were observed in a basket.On 8/19/25 at 11:15 a.m., an interview was conducted with R9 regarding the medications observed. R9 stated that she keeps the pain ointments in her room because she was undergoing chemotherapy and uses them for pain relief. R9 then said, I take my inhaler twice a day and the nurse brings it in here in the morning and leaves it with me to take it in the morning and at bedtime.On 8/19/25 at 11:40 a.m., an interview was conducted with a licensed practical…

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 staff interviews and clinical record review the facility failed to ensure reasonable care for the protection of personal property for one of eighteen residents, Resident #3 (R3). R3 did not have a personal property invoice completed upon admission to help track valuables. The Findings Include:Diagnoses for R3 included contusion of left lower leg, status post left knee surgery, obesity, depression, kidney disease, and deep vein thrombosis. The most current MDS (minimum data set) was a discharge assessment with an ARD (assessment reference date) of 08/1/2024. R3 was assessed with a cognitive score of 15 indicating cognitively intact.R3 was reviewed due to a report of possible missing medication (Ozempic brought from home to the facility) and two gift cards.Review of R3's clinical record did not evidence an inventory form had been filled out upon admission or at any time during R3's stay at the facility.On 8/19/25 at 2:30 p.m. license practical nurse (LPN #7) was interviewed regarding documentation of resident's inventory list. LPN #7 explained when a resident is admitted 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 staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care regarding assessment documentation for two of eighteen residents in the survey sample (Residents #3 and #17).The findings include:1. For Resident #3, nursing staff failed to document a descriptive assessment and immediate care interventions implemented for a skin tear. Resident #3 (R3) was admitted to the facility with diagnoses that included iron deficiency anemia, human immunodeficiency virus, gout, obesity, depression, hypertension, chronic kidney disease, anxiety, cryptococcosis, and deep vein thrombosis. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. R3's clinical record documented a Focused Head to Toe Observation form dated 6/28/24. This observation form documented, res [resident] unbuckled seatbelt in transportation van and fell onto floor recving [receiving] skin tear. This form documented an assessment of the resident that included…

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, resident interview, staff interview, clinical record review, and facility documentation review the facility staff failed to follow physician orders for two residents, Resident #10 (R10) and Resident #16 (R16) out of a survey sample of 18 residents.The findings included:Staff failed to transcribe physician orders for compression bandages, ace wraps, and discontinuation of furosemide 20 mg daily for R10.On 8/19/25 at 11:10 a.m., during an observation of R10's room, her spouse expressed concerns that lower extremity treatments were not being done. The spouse stated the last treatment occurred on the Wednesday before R10's admission on [DATE].On 8/20/25 at 9:50 a.m., an interview was conducted with the unit manager on unit one, licensed practical nurse, LPN#2 (LPN2). LPN2 stated that the resident R10 was admitted around 5 p.m. on 8/8/25, and that she had orders for, Pro-fore that was never carried over. It was missed on admission. The resident wanted to use the Pro-fore wraps for her edema,…

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, resident interview, staff interview, clinical record review, and facility documentation review the facility staff failed to administer oxygen per physician's orders, and to date and label oxygen tubing and humidifier bottle for one resident, Resident #10 (R10) out of a survey sample of 18 residents.The findings included:R10 was not being administered her ordered oxygen, and the oxygen tubing and humidifier bottle were not labeled with a date of placement.On 8/19/25 at 11:10 a.m., an observation of R10 revealed that oxygen was not being administered as ordered. The oxygen concentrator was observed in the resident's room with the humidifier bottle sitting on the floor. There was no oxygen tubing connected to the concentrator. During the observation, R10's spouse was present in the room, stated that the resident had not had the oxygen on since the previous day when it was removed and the oxygen tubing was taken out of the room. A subsequent observation of R10 on 8/19/25 at 2:45 p.m., again revealed that oxygen was not being administered per the physician'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 resident interview, staff interviews, and clinical record review, the facility staff failed to maintian a complete and accurate clinical record for one resident (Resident #17- R17) in a survey sample of eighteen residents. The findings included:For R17, who was hospitalized following an incident of rolling out of bed and sustained a hematoma, the facility staff failed to have the hospital report/records available in R17's clinical record. On the evening of 8/20/25, a clinical record review was conducted of R17's chart. According to R17's progress notes dated 7/29/25, which read, Resident rolled off of bed onto floor during ADL care. Observed skin tear to right flank area. Left thigh/knee area with edema. Resident denies pain r/t [related to] fall. Resident states that he did not hit head. MD/RP [medical doctor/responsible party] aware. On 8/21/25 at 8:10 a.m., an interview was conducted with R17. R17 explained the incident on 7/29/25 and reported, I have to use the bed pan and the aide was trying 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 staff interview, and clinical record review, the facility staff failed to complete an assessment after a fall for one of 3 residents. Resident #1 (R1) did not have documented assessment after a fall. The findings included: Diagnoses for R1 included Dementia, manic depression, and fractures secondary to falls. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/3/24. R1 was assessed with a cognitive score of 00 indicating severely cognitively impaired. R1's clinical record was reviewed regarding a falls leading to R1 being sent to the hospital and diagnosed with two rib fractures and lacerated spleen on 12/9/23. Progress notes dated 12/9/23 documented a fall had occurred at 4:16 AM while R1 was in the hallway taking off clothing. A full assessment was completed and did not show any abnormalities or injuries. R1 was assisted back to bed. Another progress note dated 12/9/23 at 12:15 PM indicated R1 had become confused, lethargic, restless, with an unsteady gait, and was hypotensive. R1 was transferred to the hospital…

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 staff interview, and clinical record review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #1, R1) in a survey sample of 3 residents. The findings included: The facility staff failed to maintain accurate documentation with regards to falls. Diagnoses for R1 included Dementia, manic depression, and fractures secondary to falls. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/3/24. R1 was assessed with a cognitive score of 00 indicating severely cognitively impaired. R1's clinical record was reviewed regarding a falls leading to R1 being sent to the hospital and diagnosed with two rib fractures and lacerated spleen on 12/9/23. Progress notes dated 12/9/23 documented a fall had occurred at 4:16 AM while R1 was in the hallway taking off clothing. A full assessment was completed and did not show any abnormalities or injuries. R1 was assisted back to bed. Another progress note dated 12/9/23 at 12:15 PM indicated R1 had become confused, lethargic, restless, with 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 a medication pass and pour observation, clinical record review, staff interview, facility document review, and during the course of a complaint investigation the facility staff failed to follow physician's order for two of 27 resident's in the survey sample (Resident #26 and Resident #95) and failed to obtain transportation to appointments for two of 27 residents (Resident #11 and #39) and failed to accurately assess skin impairments for one of 27 residents (Resident #24). 1. The facility staff failed to follow physician's orders during a medication pass and pour observation for Resident #26. 2. The facility staff failed to follow physician's orders for the administration of a chemotherapy medication for Resident #95. 3. The facility staff failed to ensure transportation for outside rehabilitation appointments for Resident #11. 4. The facility staff failed to ensure transportation to an endocrinologist appointment for #39. 5. Resident #24 had conflicting and inaccurate assessments of skin tears.…

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 staff interview, facility policy review and clinical record review, the facility staff failed to provide advance notice of a room/roommate change for one of twenty-seven residents in the survey sample. Resident #75 was moved to a new room with a new roommate without prior notification to the resident's representative. The findings include: Resident #75 was admitted to the facility with diagnoses that included Alzheimer's dementia, insomnia, hypertension, history of COVID-19, major depressive disorder, COPD (chronic obstructive pulmonary disease), cerebral infarction, hemiplegia, aphasia and dysphagia. The minimum data set (MDS) dated [DATE] assessed Resident #75 with severely impaired cognitive skills. Resident #75's clinical record documented the resident was moved to a new room with a roommate on 7/5/22. A nursing note dated 7/5/22 at 6:38 p.m. documented, Residents family present to see the resident .daughter came back to the nurses station asking why her mother was moved to another room, this nurse…

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 resident interview, staff interview and clinical record review, the facility staff failed to develop a CCP (comprehensive care plan) for one of 25 residents in the survey sample. Resident #10 did not have a care plan for smoking. Findings include: Diagnoses for Resident #10 included: Chronic obstructive pulmonary disease, cirrhosis of the liver, obesity, and chronic pain. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 4/19/22. Resident #10's cognitive score was a 13 indicating cognitively intact. On 7/19/22 at 11:44 AM during an interview with Resident #10, Resident #10 verbalized that he smokes but the the staff would not let him smoke. When asked why, Resident #10 verbalized he was unsure, stating I don't know. On 7/19/22 Resident #10's smoking assessment dated [DATE] was reviewed and documented: Resident chooses to smoke, proceed with assessment. The assessment also documented Resident #10 needed supervision while smoking based…

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, staff interview and record review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 27 in the survey sample. Resident #70's CCP was not reviewed and revised to reflect a wander guard device, which was discontinued. The findings included: Resident #70 was admitted to the facility with diagnoses that included hyperlipidemia, cerebral infarction, major depressive disorder, hypertension, Alzheimer's Disease, Dementia with behavioral disturbances, and repeated falls. The minimum data set (MDS) dated [DATE] was a quarterly, and assessed Resident #70 as moderately impaired for daily decision making with a score of 8 out of 15. The MDS assessed Resident $70 as having fluctuating periods of inattention, disorganized thinking and wandering for 1-3 days. Under Section P - Restraints, the MDS assessed Resident #70 has having a wander guard for elopement risk. Resident #70 was interviewed on 07/19/2022 at 2:30 p.m. while in laying in bed. Resident #70 was asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, the facility staff failed to meet professional standards of practice for one of 27 residents in the survey sample, (Resident #95); the facility staff documented Resident #95 received chemotherapy medication when the medication was not available for administration. Findings include: Diagnoses for Resident #95 included, but were not limited to: high blood pressure, DM (diabetes mellitus), hemiplegia, major depressive disorder, history of pulmonary embolism, and rectal cancer. Resident #95's most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was intact for daily decision making skills. On 07/20/22 Resident #95's clinical records were reviewed. The resident had a current physician's order for the chemotherapy medication, Capecitabine Tablet 500 MG (milligrams) Give 2 tablet by mouth two times a day every Mon, Tue, Wed, Thu, Fri…

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 complaint investigation, clinical record review, resident interview, and staff interview, the facility failed for one of 27 residents in the survey sample, Resident # 27, to ensure transportation for vision related medical appointments was provided. Resident # 27 missed three appointments for vision care between 5/5/2022 and 7/15/2022 due to transportation issues. The findings were: Resident # 27 in the survey was admitted with diagnoses that included acute respiratory failure with hypoxia, hypertension, gastroesophageal reflux disease, neurogenic bladder, diabetes mellitus, hyperlipidemia, thyroid disorder, cerebral palsy, paraplegia, morbid obesity, history of COVID-19, chronic renal insufficiency, chronic pain, sleep apnea, and generalized muscle weakness. According to an Annual Minimum Data Set with an Assessment Reference Date of 5/4/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section B (Hearing,…

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 staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure a complete and accurate clinical record for one of 27 residents. Resident #121's ADL (activities of daily living) forms included documentation that care was provided while she was in the hospital. Findings were: Resident #121 was admitted to the facility with the following diagnoses including but not limited to: AFTT (adult failure to thrive) schizophrenia, autoimmune hepatitis, gastrointestinal hemorrhage, history of mental and behavior problems, coronary artery disease, and transient cerebral ischemic attacks. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/16/2021 (MDS most recent to the time frame of the complaint) assessed Resident #121 as moderately impaired with a cognitive summary score of 12. A significant change MDS with an ARD of 01/18/2022 (Post hospitalization 01/11/2022-01/13/2022) assessed her as cognitively…

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 clinical record review and staff interview, the facility staff failed to accurately complete MDS (minimum data set) assessments for two of 32 residents, Resident # 35 and Resident #97. Resident #35 was not assessed as edentulous on her annual MDS and Resident #97 was not assessed as having a lap buddy since it's implementation on 09/20/2018. Findings were: 1. Resident #35 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: cognitive impairment, dysphagia, Type 2 diabetes mellitus, and hypertension. The most recent MDS was a quarterly assessment with an ARD (assessment reference date) of 12/24/2019. She was assessed as moderately impaired in her cognitive status with a summary score of 09. During interviews Resident #35 was observed to be without any teeth (edentulous). Review of the clinical record contained information that Resident #35 had her remaining teeth pulled in November of 2018. Her annual MDS with an ARD of 04/26/2019 did not provide assessment information…

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 resident interview, staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan (CCP) for one of 32 in the survey sample. Resident #121's CCP was not revised for impaired mobility and transfer assistance. Resident #121 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting the left side, bilateral osteoarthritis of the knee, chronic kidney disease - stage 2, congestive heart failure, bipolar disorder, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] which was a significant change, assessed Resident #121 as cognitively intact for daily decision making with a score of 14 out of 15. Under Section G - Functional Status, the MDS assessed the resident as extensive assistance, requiring one person physical assistance for bed mobility, dressing and eating; total dependent, requiring two person physical assistance for…

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 medication pass and pour observation, staff interview, and facility document review, the facility staff failed to administer medications per manufacturer's recommendations during medication administration on the third floor. LPN (licensed practical nurse) #1 crushed an extended release tablet of Isosorbide (a heart medication) prior to administration. The facility also failed to obtain weekly weights on 1 of 32 residents, Resident #41. Findings were: 1. A medication pass and pour observation was conducted on 03/11/2020 at approximately 8:20 a.m. on the third floor of the facility. LPN #1 was observed preparing medications for administration to Resident #51. After placing all the medications in a pill cup, he stated, She takes hers crushed in applesauce. He proceeded to place the pills in a plastic bag and crushed them, then mixed them with applesauce. He took them to Resident #51's room and administered them. After administration of the medications, LPN #1 was asked to look at the medication card for…

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, staff interview, and clinical record review, the facility failed to provide care and services to promote healing and prevent infection of a pressure ulcer for one of 32 Residents. Resident #128's pressure ulcer was left uncovered. The Findings Include: Resident #128 was admitted to the facility on [DATE] with a current readmission on [DATE]. Diagnoses for Resident #128 included: Sepsis, Urinary tract infection, and stage 3 pressure ulcer to left buttock. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 2/21/20. Resident #128 was assessed with a score of 13 indicating cognitively intact. On 03/11/20 at 11:00 AM, license practical nurse (LPN #4) was observed performing a dressing change to Resident #128's left buttock pressure ulcer. LPN #4 was assisted in turning Resident #128. Upon exposing Resident #128's buttock, it was observed that Resident #128 did not have a dressing intact. Resident #128 was laying on a protective…

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 medication pass and pour observation, staff interview, and facility document review, LPN (licensed practical nurse) #1 failed to follow infection control practices during the administration of medications on the third floor. LPN #1 was observed preparing and administering medications to two residents. He did not wash his hands with soap and water or use hand sanitizer during the observation. Findings were: A medication pass and pour observation was conducted on 03/11/2020 beginning at approximately 8:20 a.m. on the third floor of the facility. LPN #1 was observed preparing medications for administration to Resident #29 and Resident #51. LPN #1 did not wash his hands or use hand sanitizer before beginning the medication preparation for Resident #29. He entered Resident #29's room, gave the medications, and returned to the cart. He then began preparing medications for Resident #51. He did not wash his hands or use hand sanitizer between giving medications to Resident #51 and preparing medications for Resident #29. He entered Resident #29's room and administered 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.