The Laurels Of Willow Creek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for the treatment of pressure injuries for one of 37 residents in the survey sample; Resident #205. The findings include: The facility policy, Skin Management was reviewed. This policy documented, Upon admission/re-admission all guests/residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record 4. Guests/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment, and Wound location, measurements and characteristics documented The facility staff failed to document descriptions, measurements, and staging of two wounds after the initial admission documentation, until the wound care physician saw the resident approximately seven days after admission; and, failed to evidence that treatment 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, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services in a sanitary manner for one of 37 residents in the survey sample, Residents #21. The findings include: For Resident #21 (R21), the facility staff failed to store a CPAP (continuous positive airway pressure) (1) mask in a sanitary manner. R21 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive sleep apnea (2). On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 07/14/2021, R21 scored 15 out of 15 on the BIMS (brief interview for mental status), the resident was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R21 for CPAP while a resident. On 09/11/23 at approximately 12:32 p.m., an observation of R21's room revealed a CPAP mask laying on the over-the-bed table uncovered. On 09/11/23 at approximately 4:30 p.m., an observation of R21's room revealed a CPAP…

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, clinical record review and facility document review, it was determined that the facility staff failed to evidence communication with the dialysis center for each dialysis visit for one of two residents in the survey sample that received dialysis services; Resident #91. The findings include: For Resident #91, there were no dialysis communication sheets for 8/31/23, 9/2/23 and 9/9/23; and incomplete dialysis communication sheets for 8/29/23 and 9/5/23. The facility policy, Hemodialysis was reviewed. This policy documented, Guests/residents receiving hemodialysis will be assessed pre and post treatment, and receive necessary interventions 4. The facility completes the appropriate section of the hemodialysis communication form prior to guest/resident receiving each dialysis session and again when the guest/resident returns from hemodialysis . A review of the clinical record revealed an order dated 8/21/23 for dialysis on Monday, Wednesday, and Friday; and an order dated 8/30/23 changing the dialysis days to Tuesday, Thursday and Saturday. A nurse's note dated…

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

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure all bed rail requirements were met for one of 37 residents in the survey sample, Resident #87. The findings include: For Resident #87 (R87), the facility staff failed to review the risks and benefits of bed rails with the resident and obtain informed consent. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R87's clinical record revealed a physician's order dated 2/17/23 for a right assist bar (bed rail) to aide in turning and repositioning. A physical device evaluation dated 2/20/23 documented the use of an assist bar enabled increased bed mobility and enabled the resident to reposition self. On 9/11/23 at 2:48 p.m., R87 was observed lying in bed with a right assist bar in the upright position. 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.

Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to ensure a resident's needs were met for one of 37 residents in the survey sample, Resident #24. The findings include: For Resident #24 (R24) the facility staff failed to provide incontinence care due to insufficient nursing staff. R24 was admitted to the facility with diagnoses that included but were not limited to: muscle wasting and abnormalities of gait and mobility. On 09/11/23 at 12:35 p.m., an observation revealed that R24, who resided on the west unit at the facility, activated the call bell for incontinence care. On 09/11/23 at 12:45 p.m., an observation revealed CNA (certified nursing assistant) #2 entered R24's room, turned off the call and left the room with R24's lunch tray. On 09/11/2023 at 1:00 p.m., an observation revealed LPN (licensed practical nurse) #4 entered R24's room and provided incontinence care. The facility's as-worked schedule for 09/11/2023 documented eight certified nursing assistants…

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 provide a diet to meet a resident's needs for one of 37 residents in the survey sample, Resident #310. The findings include: For Resident #310 (R310), the resident was discharged from the hospital on 2/17/23 with a recommendation for a diabetic diet. The facility staff failed to obtain a physician's order for R310's diet until 2/20/23. R310 was served a regular diet until a physician's order for a consistent carbohydrate diet with no added salt was obtained on 2/20/23. A hospital orthopedic surgery progress note dated 2/16/23 documented, Assessment/Plan: Diet: diabetic . R310 was admitted to the facility on [DATE] with a diagnosis of diabetes. A review of R310's physician's orders failed to reveal any dietary orders until 2/20/23. A dietary communication form dated 2/18/23 documented the resident's diet as regular. A facility form titled, Guest/Resident, Family, Employee, and Visitor Assistance Form dated…

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

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: The facility staff failed to close a box containing a bag of breaded fish filets, exposing them to the environment, in one of one walk-in freezers. On 09/11/2023 at approximately 11:45 a.m., an observation of the facility's walk-in freezer was conducted with OSM (other staff member) #1, dietary manager. Observation of the middle shelf on the right side inside the freezer revealed a ten-pound box of breaded fish filets. Observation of the box revealed that the box and the inside packaging was open to the environment. When asked how much was left in the box OSM #1 stated it about half remaining. OSM #1 further stated that the box should have been closed and immediately removed it from the freezer. The facility's policy Food Purchasing and Storage documented in part, All frozen food will be dated, labeled, and wrapped or sealed. Moisture-proof, tightfitting materials will be used to prevent…

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, staff interview, and facility document review, it was determined that the facility staff failed to store and prepare food in a sanitary manner in one of one facility kitchens. The findings include: On 3/22/22 at 11:54 AM, the Kitchen tour was conducted with OSM #10 (Other Staff Member) the Dietary Manager. The following was noted: At 11:56 AM, food residue was observed on the meat slicer. When asked about this, OSM #10 stated that the meat slicer was supposed to be clean and ready to use, and should not have residue on it. At 12:00 PM, in the walk-in freezer, the following was observed: a box of meatless meatballs, a box of veggie chicken nuggets, a box of veggie burger patties, and a box of beef and pepper patties were all unsealed and exposed to the freezer environment. When asked about this, OSM #10 stated, How should the bags be sealed? At 12:03 PM, the reach-in fridge was noted to contain a plastic resealable style bag of smoked deli ham, which was opened with the ham exposed to the refrigerator environment. When asked about this, OSM #10 stated that the…

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

Based on observation, resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement a comprehensive care plan for 5 of 51 residents in the survey sample; Residents #216, #217, #112, and #16. The findings include: 1. The facility staff failed to follow the comprehensive care plan for providing privacy of a Foley catheter drainage bag for Resident #216. On the most recent MDS (Minimum Data Set), an admission/5-day assessment with an ARD (Assessment Reference Date) of 12/10/21, Resident #216 scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was not coded as having an indwelling catheter at that time. A review of the clinical record revealed physician's orders dated 3/3/22 for the use of a Foley catheter. On 3/22/22 at 2:28 PM, an observation was made of Resident #216. The Foley catheter bag was hanging on the side of the bed…

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, clinical record review, and facility document review, it was determined that the facility staff failed to follow professional standards of practice for 1 of 51 residents in the survey sample; Resident #80. The facility staff failed to clarify physician's orders regarding parameters for the administration of PRN (as-needed) pain medication for Resident #80. The findings include: On the most recent MDS (Minimum Data Set), an admission assessment with an ARD (Assessment Reference Date) of 2/28/22, Resident #80 scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was coded as requiring supervision to total assistance for activities of daily living. A review of the clinical record revealed a physician's order dated 2/21/22 for Tramadol (1) Tablet 50 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. A review of the clinical record also revealed a physician's order dated 2/21/22 for Acetaminophen (2) Tablet 325 MG Give 2 tablet by…

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

Based on observation, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to prepare food in a manner that was palatable for meal enjoyment. The findings include: On 3/22/22 at 5:05 PM, the dinner tray line service was observed. The temperatures were checked of each food item by OSM #13 (Other Staff Member) the dietary cook, utilizing a facility thermometer. The food temperatures were as follows: Regular meal: Pulled Pork BBQ 185 3-bean cooked salad 185 Potato wedge fries 190 Alternate meal items: Hot dogs 177 Peas 176 Chicken [NAME] 175 Puree meal items: Mashed potatoes 161 Puree chicken 175 Puree mix veggies 172 On 3/22/22 at 6:10 PM as the last service cart was being prepared, a test tray was requested from OSM #13. On 3/22/22 at 6:17 the service cart left the kitchen and was delivered to the 700 unit. The cart arrived to the unit at 6:20 PM, On 3/22/22 at 6:32 PM, once all residents were served, OSM #10 (the Dietary Manager), pulled each test tray from the cart and checked the temperatures…

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, clinical record review and facility document review, it was determined the facility staff failed to evidence a complete and accurate medical record for three of 51 residents in the survey sample, Resident #112, Resident #416 and Resident #3. The findings include: 1. A. The facility staff failed to document the 24 hour Foley output for Resident #112, per physician's order. Resident #112 was admitted to the facility with diagnosis that included but were not limited to: peripheral vascular disease and diabetes mellitus. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 3/1/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 2/22/22 revealed the following, NEED: Indwelling suprapubic catheter related to neurogenic bladder .Observe, record, report to physician no urine output. A review of the physician orders dated 2/23/22, revealed the…

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

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide privacy and dignity to 1 of 51 residents in the survey sample, Resident #216. The facility staff failed to maintain the Foley catheter bag in a manner to promote privacy and dignity for Resident #216. The findings include: On the most recent MDS (Minimum Data Set), an admission/5-day assessment with an ARD (Assessment Reference Date) of 12/10/21, Resident #216 scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was not coded as having an indwelling catheter at that time. A review of the clinical record revealed physician's orders dated 3/3/22 for the use of a Foley catheter. On 3/22/22 at 2:28 PM, an observation was made of Resident #216. The Foley catheter bag was hanging on the side of the bed closest to the door, and was viewable from the door with no privacy bag covering it. Staff was in with the…

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

Based on observation, resident interview, facility document review and clinical record review, it was determined that the facility staff failed to facilitate a resident's right for self-determination and choice for 1 of 51 residents in the survey sample, Resident #313. Resident #313 (R313) verbalized the desire for bed rails. The facility staff failed to honor this preference and assess the resident for the use of bed rails. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/22/21, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A review of R313's clinical record revealed a nurse's note dated 12/15/21 that documented, Resident new admit .has voiced concerns that [R313] wants side rails (bed rails) on .bed .is alert and oriented .uses a walker to stand and pivot only. Metal brace to .leg but .refused to let nurse do a thorough skin assessment due to .being upset about side rails. Further…

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, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 1 of 51 residents in the survey sample, Resident #35. The facility staff failed to complete the BIMS (brief interview for mental status) assessment for Resident #35's (R35) quarterly MDS assessment with an ARD (assessment reference date) of 1/14/22. The findings include: Section B of R35's quarterly MDS assessment with an ARD of 1/14/22 coded the resident as being understood. Section C0100 documented the BIMS assessment should be conducted. All of the questions related to the BIMS assessment (C0200 through C0400) and the BIMS summary score were coded with dashes, indicating the areas were not assessed. On 3/23/22 at 9:41 a.m., an interview was conducted with OSM (other staff member) #2 (the social services director). OSM #2 stated R35's BIMS interview should have been done by the ARD date but the other social worker was off sick and the BIMS, Got mixed in the shuffle. OSM #2 stated she references the CMS…

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, it was determined that the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 1 of 51 residents, Resident #62. The facility staff failed to complete a level 1 PASRR for Resident #62 who was admitted to the facility on [DATE]. The findings include: Resident #62 was admitted to the facility with diagnoses that included but were not limited to psychosis, major depressive disorder and dementia with behavioral disturbance. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/11/2022, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired for making daily decisions. Review of Resident #62's clinical record failed to evidence a level 1 PASRR. On 3/22/2022 at approximately 5:17 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the Level 1 PASRR…

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, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for 1 of 51 residents in the survey sample, Resident #316. The facility staff failed to develop Resident #316's (R316) baseline care plan to include the use of oxygen. The findings include: R316's diagnoses included acute and chronic respiratory failure. R316's admission minimum data set assessment was not completed. A nursing comprehensive evaluation dated 3/18/22 documented R316 was alert and oriented to time, place and person. The evaluation further documented R316 received oxygen therapy at four liters per minute. A review of R316's clinical record revealed a physician's order dated 3/18/22 for continuous oxygen at four liters per minute. A review of R316's baseline care plan dated 3/18/22 failed to document information regarding the resident's respiratory status or oxygen therapy. On 3/22/22 at 3:13 p.m., 3/22/22 at 4:33 p.m. and 3/23/22 at 7:51 a.m., R316 was observed in the bed room, receiving…

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, facility document review, and clinical record review, it was determined the facility staff failed to review and revise the care plan for two of 51 residents in the survey sample, Residents #53 and #216. The findings include: 1. For Resident #53 (R53), the facility staff failed to review and revise the care plan for a change in the resident's code status from a full code to a DNR (do not resuscitate). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/31/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. The physician order dated 2/15/2022, documented, Do Not Resuscitate (No CPR - cardiopulmonary resuscitation). The clinical record contained the form, Durable Do Not Resuscitate Order (DDNR) dated 11/8/2021. The review of the comprehensive care plan dated 1/5/2022 documented in part, Need: [R53] is a full code .Facility will make attempts to sustain life in…

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, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide treatment to promote healing of a pressure injury for 1 of 51 residents in the survey sample, Resident #3. The facility staff failed to follow professional standards of care when providing treatment to Resident #3's pressure injury on 3/23/2022. LPN (licensed practical nurse) #1 was observed using one piece of gauze to clean off three separate pressure injuries located on Resident #3. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section M documented Resident #3 having two Stage 4 pressure ulcers. On 3/23/2022 at 9:47 a.m., an observation was made of ASM (administrative staff member) #6, wound physician, assessing…

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, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide respiratory services for three of 51 residents in the survey sample, Residents #1, #316 and #16. The findings include: 1. The facility staff failed to store Resident #1's nebulizer in a sanitary manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/25/2022, the resident scored 15 of 15 on the BIMS (brief interview for mental assessment), indicating the resident is cognitively intact for making daily decisions. Section O documented Resident #1 receiving oxygen while a resident at the facility, and as receiving respiratory therapy 7 days during the assessment period. On 3/22/2022 at approximately 1:20 p.m., an interview was conducted with Resident #1 in their room. Resident #1 was observed sitting in a wheelchair beside the bed. A nebulizer delivery device with mask attachment sat…

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, staff interview, clinical record review, and facility document review, the facility staff failed to prevent a resident from receiving an unnecessary medication for one five residents in the medication administration observation, Resident #9. The facility staffadministered a double dose of nasal spray to Resident #9. The findings include: On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 12/30/2021, the resident was coded as scoring a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. Observation was made of LPN (licensed practical nurse) #4 administering medications to R3 on 3/23/2022 at 8:15 a.m. LPN #4 administered all of the oral medications, and then administered the nasal spray, Fluticasone Propionate (Flonase) Nasal Spray (used for the management of nasal symptoms of perennial nonallergic[sic] rhinitis) (1). LPN #4 administered two sprays in each nostril. After LPN #4 had finished administering…

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 document review, it was determined the facility staff failed to evidence a bed inspection was provided for one of 51 residents in the survey sample, Resident #412. The facility staff failed to perform bed rail inspections for the use of positioning/assist bars for Resident #412. The findings include: Resident #412 was admitted to the facility with diagnoses that included but were not limited to: diabetes mellitus and morbid obesity. Resident #412's most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an assessment reference date of 3/14/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. On 3/22/22 at 1:20 PM and 3/23/22 at 8:20 AM , Resident #412 was resting in bed, with half rails raised on the left side of the bed. A review of the physician order dated 3/21/22, revealed the following:…

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, resident interview, staff interview, family interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to maintain and clean, comfortable, homelike environment for two of 53 residents in the survey sample, Residents #20 and #92 and for 74 of 78 resident rooms. 1. The facility staff failed to clean and store a bedpan in a sanitary manner and failed to repair a hole in the cove base at the bottom of the wall in Resident #20's bathroom. 2. The facility staff failed to maintain Resident #92's bathroom in a sanitary manner and failed to repair a hole in the cove base at the bottom of the wall. 3. The facility staff failed to maintain the heating/air conditioning units in rooms #103, #104, #105, #108, #109, #200, #202, #203, #204, #206, #209, #301, #302, #307, #401, #402, #501, #601, #606 and #705 in a clean and comfortable manner. 4. The facility staff failed to ensure light covers in multiple resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services consistent with professional standards of practice for four of 53 residents in the survey sample, Residents # 9, # 104, # 55, and # 23. 1. The facility staff failed to store Resident # 9's BI-PAP [bi-level positive air pressure] (1) mask and tubing in a sanitary manner. During multiple observations of Resident 9's BI-PAP mask and tubing, revealed the mask was stored uncovered and not in a bag. 2. The facility staff failed to administer Resident #104's oxygen according to physician's orders. 3. The facility staff failed to administer Resident #55's oxygen according to the physician's order. 4. The facility staff failed to store Resident #23's respiratory equipment in a sanitary manner. The findings include: 1. The facility staff failed to store Resident # 9's BI -PAP (continuous positive air pressure) mask and tubing in a sanitary manner. Resident # 9 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 and staff interview, the facility staff failed to prepare and serve food in a sanitary manner in the kitchen. A dietary aide failed to secure their hair properly in a hair net, failed to wash their hands before beginning food preparation, and touched the eating surface of food plates with un-gloved hands. The findings include: A tour of the facility kitchen was conducted on 03/12/2019 at 10:45a.m. An observation of the food preparation and tray line was conducted at 11:30a.m., with Other Staff Member (OSM) #14, a cook. At the beginning of the tray line, OSM #7, a Dietary staff member, was observed leaving the manager's office and walking directly to the tray line to begin assembling resident meal trays. OSM #7 was not observed washing their hands after leaving the manager's office, which entailed touching the doorknob, and was not wearing gloves. During the tray assembly process, OSM #14 was observed filling trays with food, then placing them on top of the service line for OSM #7 to place onto trays, then OSM #7 placed those trays into the meal delivery cart.…

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, facility document review and clinical record review, it was determined that the facility staff failed to serve food in a manner to promote resident dignity for one of 53 residents in the survey sample, Resident # 264. The facility staff failed to serve food in a manner to promote dignity in the facility's main dining room. Resident # 264 waited twenty-two minutes to receive her lunch meal, after her tablemate was served and eating the lunch meal. The findings include Resident # 264 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fractured right hip and swallowing difficulty. Resident # 264's MDS (minimum data set) was not due to be completed at the time of the survey. The facility's nursing admission assessment dated [DATE] documented Resident # 264 was orientated to person, non-weight bearing and totally dependent of staff for transfers and toileting. The baseline care plan for Resident # 264 dated 03/11/2019 documented, ADL…

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, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for two of 53 residents in the survey sample, Residents #87 and #89. 1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to implement the abuse policy for reporting and completing a thorough investigation of the allegation. 2. The facility staff failed to implement the abuse policy for reporting a resident-to-resident altercation when Resident # 89 received a scratch under their eye on 12/07/18. The findings include: 1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to implement the abuse policy for reporting and completing a thorough investigation of the allegation. Resident #37 was admitted to the facility on [DATE]. Resident #37's diagnoses included but were not limited to high blood pressure,…

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, facility document review and clinical record review, it was determined that the facility staff failed to report allegations of abuse within the required time frame for two of 53 residents in the survey sample, Residents #87 and #89. 1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to report this allegation to the state agency and other agencies according to law. 2. The facility staff failed to ensure timely reporting to the State Agency and other officials in accordance with state law when Resident # 89 received a scratch under their eye on 12/07/18 during a resident to resident altercation. The incident was not reported until 12/10/18. The findings include: 1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to report this allegation to the state agency and other agencies according to law. Resident #37 was admitted to the facility 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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to complete a thorough abuse investigation for one of 53 residents in the survey sample, Resident #87. On 2/14/19, Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to conduct a complete and thorough investigation regarding this allegation. The findings include: Resident #37 was admitted to the facility on [DATE]. Resident #37's diagnoses included but were not limited to high blood pressure, major depressive disorder and delusional disorders. Resident #37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/30/19, coded the resident as being cognitively intact. Section G coded Resident #37 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene. Resident #87 was admitted to the facility on [DATE]. Resident #87's diagnoses…

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, it was determined the facility staff failed to evidence that all required information, including comprehensive care plan goals, was provided to the receiving hospital when one of 53 residents in the survey sample, Resident #20, was transferred to the hospital on [DATE] and 12/24/18. The facility staff failed to provide the receiving hospital with the Resident #20's comprehensive care plan goals during a facility initiated transfer to the hospital on [DATE] and 12/24/18. The findings include: Resident #20 was admitted to the facility on [DATE] with a recent with diagnoses that included but were not limited to, heart failure, sleep apnea [a condition in which the patient has transient periods of apnea during sleep (1)], obesity, diabetes and depression. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/10/19, coded the resident as scoring a 15 on the BIMS (brief…

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 and clinical record review, it was determined the facility staff failed to provide written notification to the resident and/or resident representative and/or ombudsman of a facility initiated transfer for two for 53 residents in the survey sample, Residents #20 and #50. 1. The facility staff failed to provide written notification to Resident #20 or the responsible representative for the 12/17/18 and 12/24/18 facility initiated transfers to the hospital. 2. The facility staff failed to provide evidence that the Ombudsman was provided written notification of Resident #50's facility initiated transfer to the hospital on 1/14/19. The findings include: 1. The facility staff failed to provide written notification to Resident #20 or the responsible representative for the 12/17/18 and 12/24/18 facility initiated transfers to the hospital. Resident #20 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, heart failure, sleep apnea [a condition in which 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 staff interview, clinical record review and facility document review, it was determined that facility staff failed to update a baseline care plan for one of 53 residents in the survey sample, Resident # 53. The facility staff failed to update Resident # 53's baseline care plan concerning a fall on 02/11/19. The findings include: The facility staff failed to update Resident # 53's baseline care plan concerning a fall on 02/11/19. Resident # 53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: muscle weakness, abnormalities of gait and mobility, cerebral infarction (1), aphasia (2), and hypertension (3). Resident # 53s most recent comprehensive MDS (minimum [NAME] set) an admission assessment with an ARD (assessment reference date) of 02/15/19 coded the resident as scoring a 99 on the brief interview for mental status (BIMS) of a score of 0 - 15, 99 coded Resident # 53 as being unable to complete the brief interview for mental status. Under Staff Assessment 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for two of 53 residents in the survey sample, Residents #36, and #50. 1. The facility staff failed to develop a care plan to address Resident #36's urinary incontinence. 2. The facility staff failed to develop a comprehensive care plan to include Resident #50's risk for altered nutritional status based on the triggered Care Area Assessment (CAA) Summary - Nutritional Status from the Minimum Data Set (MDS) Section V dated 1/17/19. The findings include: 1. The facility staff failed to develop a care plan to address Resident #36's urinary incontinence. Resident #36 was admitted to the facility on [DATE]. Resident #36's diagnoses included but were not limited to diabetes, high blood pressure and difficulty swallowing. Resident #36's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the care plan for two of 53 residents in the survey sample, Resident # 53, and # 55. 1. The facility staff failed to update Resident # 53's comprehensive care plan concerning a fall on 02/15/19. 2. The facility staff failed to review and revise Resident #55's care plan to include oxygen administration. The findings include: 1. The facility staff failed to update Resident # 53's comprehensive care plan concerning a fall on 02/15/19. Resident # 53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: muscle weakness, abnormalities of gait and mobility, cerebral infarction (1), aphasia (2), and hypertension (3). Resident # 53s most recent comprehensive MDS (minimum [NAME] set) an admission assessment with an ARD (assessment reference date) of 02/15/19 coded the resident as scoring a 99 on the brief interview for mental…

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, it was determined that the facility staff failed to follow professional standards of practice for two of 53 residents in the survey sample, Residents #315 and #265. 1. The facility staff failed to clarify Resident #315's physician order regarding instruction for the removal of a lidocaine patch. 2. The facility staff failed to ensure that the physicians order for Resident # 265's prednisone (1) was transcribed to the MAR (medication administration record) accurately, resulting in Resident #265 not receiving the prescribed medication from June 12, 2018 through June 18, 2018. The findings include: 1. Resident #315 was admitted to the facility on [DATE]. Resident #315's diagnoses included but were not limited to multiple rib fractures, dislocation of left shoulder and diabetes. Resident #315's 14 day Medicare MDS (minimum data set) assessment with an ARD (assessment reference date) of 8/8/18, coded the resident's cognition as moderately impaired.…

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, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to provide the necessary services to maintain good grooming, and personal hygiene for one of 53 residents in the survey sample, Resident #315. The facility staff failed to provide a shower and/or bath from 7/30/18 through 8/13/18, to Resident #315, who was coded as requiring extensive assistance of one with Activities of daily living. The findings include: Resident #315 was admitted to the facility on [DATE]. Resident #315's diagnoses included but were not limited to multiple rib fractures, dislocation of left shoulder and diabetes. Resident #315's 14 day Medicare MDS (minimum data set) assessment with an ARD (assessment reference date) of 8/8/18, coded the resident's cognition as moderately impaired. Section G coded Resident #315 as requiring extensive assistance of two or more staff with bed mobility/transfers and as requiring extensive…

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, it was determined the facility staff failed to ensure two of 53 sampled residents, (Resident #92 and Resident #265), received treatment and care in accordance with professional standards of practice and the comprehensive care plan. 1. The facility staff failed to have blood work drawn according to the physician orders for Resident #92. 2. The facility staff failed to administer Resident # 265's was prednisone (1) as prescribed by the physician. Resident #265's prednisone was not transcribed to the MAR (medication administration record) accurately, resulting in Resident #265 not receiving the prescribed medication from June 12, 2018 through June 18, 2018. The findings include: 1. Resident #92 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: brain cancer, muscle weakness, diabetes, depression, and high blood pressure. The most recent MDS (minimum data set) assessment, a Medicare 30 day…

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, family interview, facility document review and clinical record review, it was determined the facility staff failed to provide treatment and services to maintain or restore bladder and bowel function for one of 53 residents in the survey sample, Resident #92. The facility staff failed to implement a toileting plan to maintain or restore Resident #92's bladder and bowel function. The findings include: Resident #92 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: brain cancer, muscle weakness, diabetes, depression, and high blood pressure. The Nursing Comprehensive Evaluation dated, 1/24/19, documented in part, under Section F. Genitourinary that the resident was continent of both bowel and bladder. The MDS (minimum data set) assessment, an admission/Medicare Five day assessment, with an assessment reference date of 1/31/19, coded the resident in Section H - Bladder and Bowel as being frequently incontinent of bowel and bladder (2 or more…

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 facility document review, it was determined that the facility staff failed to ensure eight consecutive hours of RN (registered nurse) coverage. The facility staff failed to ensure eight consecutive hours of RN coverage for four days, 2/16/19, 3/2/19, 3/3/19 and 3/9/19. The findings include: Review of facility staffing coverage for 2/10/19-3/14/19, revealed the facility failed to staff a RN for eight consecutive hours on 2/16/19, 3/2/19, 3/3/19 and 3/9/19. On 3/13/19 at approximately 8:17 a.m., an interview was conducted with OSM (other staff member) #8 (the staffing coordinator). OSM #8 was asked if she was aware that there was not eight consecutive hours of RN coverage on 2/16/19, 3/2/19, 3/3/19 and 3/9/19. OSM #8 stated that she was aware. OSM #8 was asked if she knew why it was important to have eight consecutive hours of RN coverage daily. OSM #8 stated that eight consecutive hours of RN coverage is needed for supervision of licensed practical nurses, certified nurse aides and to assess residents as needed. OSM #8 stated that if an RN isn't on 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 53 residents in the survey sample, received the treatment and care in accordance with professional standards of practice and the comprehensive care plan for Resident #92. The facility staff failed to obtain physician ordered laboratory tests for Resident #92. The findings include: Resident #92 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: brain cancer, muscle weakness, diabetes, depression, and high blood pressure. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/20/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable or making daily cognitive decisions. The physician order dated 1/25/19 documented, CBC* and CMP weekly starting on 1/28/19. *A complete blood count or CBC is a blood…

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, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement infection control practices for one of 53 residents in the survey sample, and in the kitchen, Residents #164. The facility staff failed to ensure the implementation of contact isolation precautions for Resident #164. The findings include: Resident #164 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: amputation of right great toe, MRSA [MRSA stands for methicillin-resistant Staphylococcus aureus. It causes a staph infection [pronounced staff infection] that is resistant to several common antibiotics. (1)], high blood pressure, diabetes, heart failure and has a colostomy [a surgical creation of an opening in the abdominal wall to allow material to pass from the bowel through that opening (2)]. There was no completed MDS (minimum data set) assessment. The Nursing Comprehensive Evaluation dated, 3/7/19,…

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.