Kin On Health Care Center

Based on observation, interview, and record review, the facility failed to ensure Transmission Based Precautions (TBP- measures put in place to prevent spread of infection by staff wearing Personal Protective Equipment [PPE-use of gown, gloves, mask and/or face shield/goggles] before entering a resident's room or environment) practices were followed for 1 of 1 resident (Resident 99), and failed to follow Enhanced Barrier Precautions (EBP- protocols to protect residents from multidrug-resistant organisms [a germ that is resistant to medications that treat infections]) practices were followed by 1 of 3 staff (Staff T), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection, related complications and a diminished quality of life. Findings included. Review of the facility's policy titled, Transmission-Based (Isolation) Precautions, revised on 02/20/2026, showed, The facility will use standard approaches, as defined by the CDC [Centers for Disease Control and Prevention], for transmission-based precautions: airborne…

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

Based on interview and record review, the facility failed to ensure injuries of unknown source and abuse allegations were thoroughly investigated for 4 of 5 residents (Residents 1, 2, 3 & 4), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed that injuries of unknown source meant any injury sustained by a resident where the source of the injury was Not observed directly by a staff person . The resident is not able to report/inform how the injury occurred .Injuries of unknown source may be either superficial or substantial in nature. It showed, Substantial injuries require more than first aid and may require close assessment and monitoring by nursing or medical staff. They also include injuries occurring in areas not generally vulnerable to trauma .Substantial injuries of unknown source, even if they do not appear to be due to abuse or neglect, must be reported 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 interview and record review, the facility failed to ensure the attending physician reviewed the total program of care including treatment and medications and completed progress notes timely for 38 of 38 residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 & 42), reviewed for physician progress notes. This failure had the potential to place the residents at risk for a delay in treatment, unmet medical care needs, and lack of physician oversight. Findings included . Review of the complaint hotline form dated 03/05/2025, showed the facility submitted to the state agency that there are concerns in regard to the Medical Director [Staff D] and his medical duties. Review of the incident investigation dated 03/04/2025, showed that Staff D saw around 40 residents [Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 & 42] here at the facility and was also the Medical Director.…

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

Based on interview and record review, the facility failed to report significant injury of unknown origin for 1 of 5 residents (Resident 3) reviewed for abuse investigations. The facility's failure to report large bruises of unknown origin on the resident's chest and torso, placed the residents at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source .are reported to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). It showed that Injuries of unknown source means any injury sustained by a resident where the source of the injury was .not observed by a staff person .the resident is not able to report/inform how the injury occurred. It further showed that substantial injuries (including bruises occurring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to provide care and services in a manner that maintained and promoted dignity before entering resident rooms for 4 of 11 rooms (Rooms 121, 122, 126 & 119), reviewed for dignity. This failure placed the residents at risk for a diminished self-worth and over-all well-being. Findings included . Review of the facility's policy titled, Resident Rights, revised on 10/17/2024, showed the resident has a right to be treated with respect and dignity. room [ROOM NUMBER] Multiple observations on 02/20/2025 at 8:55 AM, at 9:01 AM, at 9:11 AM, and at 9:20 AM, showed Staff R, Licensed Practical Nurse, entered room [ROOM NUMBER] without knocking or identifying themselves to the residents prior to entering. room [ROOM NUMBER] Multiple observations on 02/20/2025 at 8:56 AM, at 12:22 PM, and at 12:46 PM, showed Staff R entered room [ROOM NUMBER] without knocking or identifying themselves to the residents prior to entering. room [ROOM NUMBER] Observations…

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

Based on observation, interview, and record review, the facility failed to ensure the survey result binder included the recertification and complaint survey results that resulted in citations for 2 of 3 years (2022 & 2024), reviewed for availability of survey reports. In addition, the facility failed to post notice of the availability of survey reports in areas of the facility that are prominent and accessible to the public. These failures prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of corrections. Findings included . Review of the facility's policy titled, Availability of Survey Results, revised on 02/25/2025, showed, The facility will maintain reports of any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility. This information will be available for any individual to review upon request. The policy further showed, Signs identifying the availability and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement care plans for 7 of 8 residents (Residents 43, 78, 1, 9, 80, 3 & 85), reviewed for care planning. The failure to develop person-centered care plans for use of bed rails placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised on 02/17/2025, showed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing .and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The policy further showed that comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS-an assessment tool) assessment. Review of the facility's policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise comprehensive care plans for 4 of 18 residents (Residents 76, 1, 492 & 58), reviewed for care plan revision. The failure to revise care plans for residents with diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), missing/broken denture and discharge planning placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised on 02/17/2025, showed, The comprehensive care plan will be reviewed and revised by the interdisciplinary team [IDT-therapy, nursing, social services] after each comprehensive and quarterly MDS [Minimum Data Set- an assessment tool] assessment. Review of the facility's policy titled, Discharge Planning Process, revised on 02/17/2025, showed that subsequent assessment information and discharge goals would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to comprehensively assess residents for the use of bed rails for 7 of 8 residents (Residents 1, 9, 80, 3, 43, 78 & 85) reviewed for bed rails. This failure placed residents at risk for potential injury, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Proper Use of Bed Rails, revised on 02/24/2025, showed, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails .Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars [enabler] .The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternativeness failed to meet the resident's assessed needs .The resident assessment must also assess the resident's risk from using bed rails . the medical record should include evidence…

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

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked after the start of each shift for 5 of 7 days (02/19/2025, 02/20/25, 02/21/2025, 02/24/2025 & 02/26/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's policy titled, Nurse Staffing Posting Information, revised on 02/25/2025, showed that the nurse staffing form will be posted daily and will include the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. It further showed that, The information shall reflect staff absences on that shift due to call-outs and illness. After the start of each shift, actual hours will be updated to reflect such. An observation on 02/18/2025 at 10:01 AM, showed posted signage at Nursing Station 2 that listed nursing staff shift hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided per professional standards of practice for 4 of 9 residents (Residents 39, 14, 49 & 6), reviewed for medication management. The failure to clarify physician's order, document medication, and properly identify residents prior to medication administration placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Administration, revised on 02/24/2025, showed that Medications are administered .as ordered by the physician and in accordance with professional standards of practice .identify resident by photo in the MAR (medication administration record). The policy further showed to ensure that the six rights of medication administration were followed: right resident, right drug, right dosage, right route, right time, right documentation and to sign the MAR after administration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were monitored for safe storage of vaccines (biological preparation that provides immunity to a particular disease) were followed for 1 of 1 medication room refrigerator (Station 2 Medication Room Refrigerator), and failed to ensure expired medical supplies and/or biologicals (diverse group of medicines made from natural sources) were removed or discarded in accordance with current accepted professional standards for 1 of 1 clean utility room (Station 2 Clean Utility Room), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications and medical supplies. Findings included . According to the Centers for Disease Control and Prevention (CDC) website titled, Vaccine Storage and Handling, dated [DATE], showed, To ensure the safety of vaccines, the storage unit minimum and maximum temperatures should be checked and recorded at…

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

Based on observation, interview, and record review, the facility failed to ensure the sanitizing solution/agent was at the correct concentration used to ensure proper sanitation of food preparation surfaces in accordance with professional standards for 1 of 1 kitchen, reviewed for food safety. This failure placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Safety Requirements, revised on 01/24/2025, showed that all equipment used in the handling of food shall be cleaned and sanitized, and handle in a manner to prevent contamination. The policy further showed, staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. The facility procedure showed that staff clean/wipe with detergent solution, rinsed with hot water, wipe with sanitizing solution, and air dry. Review of the undated online document titled, Washington State Food Worker Manual, showed, Sanitizer solution stops working overtime.…

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

Based on observation, interview, and record review, the facility failed to report a communicable disease (infectious disease that can spread through direct or indirect contact) outbreak (two or more cases of a highly contagious disease) for 1 of 1 outbreak, and failed to ensure proper infection control practices were followed during resident care and medication administration for 2 of 12 residents (Resident 65 & 6), reviewed for infection control. In addition, the facility failed to ensure Transmission Based Precautions (TBP- additional infection control measures used when standard precautions are not enough to prevent the spread of an infection) practices were followed for 2 of 7 residents (Residents 11 & 57). These failures placed the residents, staff, and visitors at an increased risk of infection and related complications. Findings included . Review of the facility's policy titled, Communicable Disease (Infection Control Reporting) Policy, revised on 02/25/2025, showed it was the facility policy to timely report possible incidents of communicable disease or infections to the…

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

Based on interview, and record review, the facility failed to initiate and resolve a grievance for 1 of 3 residents (Resident 1), reviewed for grievances. The failure to initiate, investigate, and resolve grievances for missing personal item placed the resident at risk for feelings of frustration, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident and Family Grievances, revised on 07/08/2024, showed, The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations .The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. Review of the Quarterly Minimum Data Set (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 interview and record review, the facility failed to ensure injuries of unknown source and falls were thoroughly investigated for 2 of 2 residents (Residents 81 & 65), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Incidents and Accidents, revised on 02/25/2025, showed, It is the policy of this facility for staff to utilize Point Click Care (Risk Management System) to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The policy showed the purpose of incident reporting included assuring that appropriate and immediate interventions were implemented, corrective actions were taken to prevent recurrences, improve the management of resident care, conducting root cause analysis, and meeting regulatory requirements for analysis and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess 2 of 18 residents (Residents 1 & 57), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments of the MDS Section L (Oral/Dental Status) and Section N (Medications) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), intellectual disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) form was accurate and sent out for a Level II PASARR referral for 1 of 5 residents (Resident 58), reviewed for unnecessary medications. This failure placed the resident at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, revised on 02/21/2025, showed the Social Services Director (SSD) or designee was responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. Resident 58 admitted to the facility on [DATE]. Review of Resident 58's face sheet printed on 02/26/2025 showed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate staff supervision and/or assistance was provided during meals for 1 of 2 residents (Resident 65) and failed to ensure bed rails/enablers were secured for 1 of 5 residents (Residents 3), reviewed for accident hazards. These failures placed the residents at risk for choking episodes, aspiration (when food or liquid enters the airways or lungs), accidents, injury, and other negative outcomes. Findings included . RESIDENT 65 Review of Resident 65's nutrition care plan, initiated on 11/23/2023, showed an intervention for one to one [1 on 1] supervision assist for aspiration precautions. Review of Resident 65's February 2025 physician order summary report, printed on 02/24/2025, showed a physician order for regular diet with 1 to 1 supervision assist. Further review showed another physician order for aspiration precaution: strict 1 to 1 feeding assist, check for pocketing. Sit fully upright for all PO [by mouth]. Remain fully…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monthly pharmacy recommendations were followed up on for 1 of 5 residents (Resident 76), reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary medications and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Regimen Review, revised on 02/24/2025, showed, Facility Staff shall act upon all recommendations according to procedures for addressing medication Regimen Review irregularities. Review of Resident 76's admission record printed on 02/25/2025 showed that they readmitted to the facility on [DATE]. Review of the facility provided Pharmacy Drug Medication Review binder showed a document titled, Current Resident listing for [facility's name] with Medication Regimen Review activity between 01/01/2025 and 01/13/2025 had Resident 76 listed on the document. Further review showed no documentation of a pharmacy recommendation for Resident 76. In 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.

Based on interview and record review the facility failed to ensure allegations of financial exploitation was thoroughly investigated for 1 of 1 resident (Resident 1), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified financial exploitation, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse, Neglect and Exploitation, date implemented on 09/07/2023 showed, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Review of the Nursing Home Guidelines, The Purple Book, revised in 2015, showed that all alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. Review of the significant change in status Minimum Data Set (an assessment tool) dated 11/26/2024 showed Resident 1 had intact cognition. In an interview on 12/12/2024 at 11:23 AM,…

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

Based on interview and record review, the facility failed to provide care and services consistent with professional standards of practice related to managing signs and symptoms and/or treatment of urinary tract infection (UTI-bladder infection) for 1 of 1 resident (Resident 2), reviewed for quality of care. This failure placed the resident at risk of unmet care needs, medical complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Antibiotic Stewardship Program, implemented on 05/23/2023, showed, The facility uses the (CDC's [Centers for Disease Control and Prevention] NHSN [National Healthcare Safety Network] Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections. Review of the facility's undated document titled, Revised McGeer Criteria [used for retrospectively counting true infections] for Infection Surveillance Checklist, showed that a new or marked increase in urine frequency and a laboratory result of an organism equal or more than100,000 colony forming units (cfu-a unit that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure possible allegations of abuse were investigated for 4 of 4 residents (Residents 1, 2, 3 & 4), reviewed for abuse investigations. This failure placed the residents at risk for unidentified abuse, and a diminished quality of life. Findings included . Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 09/07/2023, showed physical marks such as bruises or physical injury of a resident of unknown source were possible indicators of abuse. The policy also showed that an immediate investigation would be warranted when suspicion of abuse occurred. The policy further showed an investigation would be completed and have thorough documentation. RESIDENT 1 Record review of the quarterly Minimum Data Set (MDS - an assessment tool), dated 07/18/2024, showed Resident 1 admitted to the facility on [DATE] AND had moderately impaired cognition. Review of Resident 1's nursing progress note dated 07/25/2024 showed that a 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.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice to ensure 5 of 6 licensed staff (Staff O, DD, EE, FF & N) observed for medication administration follow medication administration practices regarding crushing medications, Insulin (a medication to manage blood sugar) administration, Lidocaine patch (pain medication) application, clarifying physician orders and signing off medications. These failures placed the residents at risk for possible medication errors, potential negative outcomes, and a diminished quality of life. Findings included . Review of the facility's policy titled, Insulin Pen [individual pre-filled device to deliver Insulin], revised on 01/02/2024, showed Insulin pens will be primed [removing air bubbles from the needle] prior to each use to avoid collection of air in the Insulin reservoir. Review of the facility's policy titled, Medication Administration, revised on 01/02/2024, showed a policy to compare medication source [bubble pack, vial, etc.] with MAR [Medication Administration Record] to verify…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). The failure to properly administer 4 of 26 medications for 4 of 8 residents (Residents 34, 52, 59 & 69), observed during medication pass resulted in a medication error rate of 15.38%. This failure placed the residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . Review of the facility's policy tilted, Medication Administration, revised on 01/02/2024, showed a policy to compare medication source (bubble pack, vial, etc.) with MAR [Medication Administration Record] to verify resident name, form, dose, route, and time. Additionally, the policy provided example of medications that should not be crushed, which included slow-release (also known as extended release [ER]) medications. RESIDENT 34 Observation on 12/29/2023 at 8:28 AM, showed Staff O, Registered Nurse (RN), was crushing Metoprolol ER (medication to treat high blood pressure) to give to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure expired laboratory/medical supplies were discarded for 1 of 2 medication storage room (Station 2 Medication Room), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised medical supplies, possible infections, and adverse consequences. Findings included . Review of the facility's policy titled Medication Storage, revised on 01/03/2024, showed the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels. Joint observation and interview on 12/29/2023 at 8:07 AM with Staff L, Registered Nurse, showed the Station 2 Medication Room had the following expired laboratory and medical supplies: - One BD Vacutainer Trace Element Serum (a brand of blood collection tube) with an expiration date of 12/31/2018. - One BD Vacutainer Trace Element Serum with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen, 1 of 1 dining room, and 1 of 2 station units (Station 1 Unit), reviewed for food services. The failure to label and date food items and perform hand hygiene prior/after serving food placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food safety Requirements, revised on 01/02/2024, showed that practices to maintain safe refrigerated storage included labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded. It also showed that foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hand hygiene practices and proper glove use were followed during glove changes for 1 of 2 staff (Staff V), failed to clean and disinfect resident-care equipment after use for 1 of 1 resident room (room [ROOM NUMBER]), and failed to ensure clean linens were transported properly. These failures placed the residents at risk for facility acquired or healthcare-associated infections, and related complications. Findings included . HAND HYGEINE Review of the facility's policy titled, Infection Prevention and Control Program, implemented on 05/23/2023, showed that hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. Review of the facility's policy titled, Hand Hygiene reviewed/revised on 12/29/2023, directed staff to perform hand hygiene prior to donning (put on) gloves, and immediately after removing gloves. The policy also directed staff to rub hands together, when using alcohol hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident and/or their designated representative were notified before administering a psychotropic (mind altering) medication for 1 of 5 residents (Resident 95), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their medication. Findings included . Review of the facility's policy titled, Use of Psychotropic Medication, reviewed on 01/02/2024, showed that Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use. Resident 95 readmitted to the facility on [DATE]. Review of Resident 95's December 2023 Medication Administration Record showed that Olanzapine (an antipsychotic, a type of psychotropic medication used to treat certain mental/mood disorders) was prescribed and given to Resident 95 starting on 12/23/2023. Review of Resident 95's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure advance directives (healthcare directives) were offered to residents and/or their representatives for 3 of 4 residents (Residents 5, 6 & 1), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations. Findings included . Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, revised in [DATE], showed that on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. Upon admission, should the resident have 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 interview and record review, the facility failed to provide a written transfer/discharge notice to the residents/representatives and to the Office of the State Long-Term Care Ombudsman (an advocacy group for residents in a nursing home) describing the reason for transfers for 3 of 4 residents (Residents 27, 72 & 95), reviewed for hospitalization. This failure placed the residents at risk for not having an opportunity to make informed decision about transfers/discharge and access to an advocate who informed residents about options and residents rights. Findings included . Review of the facility's policy titled, Transfer and Discharge [including discharge Against Medical Advice], revised on 12/29/2023, showed that the transfer/discharge notice will be provided to the resident and resident's representative in a language and manner they can understand. The policy also showed that the notice must be provided to the resident, resident's representative if appropriate, and the Long-Term Care Ombudsman as soon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written summary of the baseline care plan to the residents and/or their representatives for 3 of 3 residents (Residents 248, 249 & 198), reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Baseline Care Plan, revised on 12/29/2023, showed a written summary of the baseline care plan shall be provided to the resident and/or their representative in a language that the resident and/or resident representative can understand. Staff responsible to provide the written summary shall obtain a signature from the resident and representative to verify that the summary was provided, and a copy shall be saved for medical records. RESIDENT 248 Resident 248 admitted to the facility on [DATE]. Review of Resident 248's clinical record, showed no documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop comprehensive care plans for 1 of 23 residents (Resident 32), reviewed for care planning. The failure to identify the resident's preferred spoken language placed the resident at risk for communication difficulty, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised on 12/29/2023, showed the comprehensive care plan will describe at a minimum Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. Resident 32 admitted to the facility on [DATE]. Review of the quarterly Minimum Date Set (an assessment tool) dated 10/31/2023, showed Resident 32's preferred language was Cantonese…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plan interventions were revised for 2 of 2 residents (Residents 23 & 36), reviewed for care planning. This failure placed the residents at risk for skin breakdown, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised on 12/29/2023 showed, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. RESIDENT 23 Resident 23 admitted to the facility on [DATE] with a diagnosis that included vascular dementia (problems with thought processes caused by brain damage from impaired blood flow). Review of the significant change in status MDS dated [DATE] showed Resident 23 was dependent with eating. Review of the activities of daily living eating care task from 12/04/2023 to 01/02/2024, showed staff provided Resident 23 with total dependence-full…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide turning and repositioning per plan of care for 1 of 6 residents (Resident 10), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for unmet care needs, skin impairment, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living, revised on 01/02/2024, showed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Resident 10 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 11/29/2023, showed Resident 10 had severely impaired cognition, functional limitation to both upper extremities (arms/hands), and required total assistance with rolling from back to left and right side on the bed. Further review of the quarterly MDS showed Resident 10 was on a turning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 6 residents (Resident 25), reviewed for accidents. The failure to provide necessary supervision placed the resident at risk for accidents, injury, and other negative outcomes. Findings included . Resident 25 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 09/11/2023 showed Resident 25 required extensive assistance with toileting. Review of the susceptibility to hazard care plan intervention revised on 10/14/2022, showed when resident uses toilet/commode don't leave resident alone. Additionally, the fall risk care plan revised on 12/22/2022, showed nursing staff will .check for safety and not leave resident unattended in her room or when using the toilet. Observation on 12/26/2023 at 1:02 PM, showed Resident 25 was self-propelling their wheelchair into the bathroom located in the tub/shower room on Station 1. A sign on the door to the tub/shower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and services for 2 of 2 residents (Resident 82 & 73), reviewed for urinary catheter. The failure to ensure urinary catheter was off the floor placed the residents at risk for infections and related complications. Findings included . RESIDENT 82 Resident 82 admitted to the facility on [DATE] with a diagnosis that included urine retention (difficulty urinating and completely emptying the bladder). Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 11/28/2023 showed Resident 82 had an indwelling foley/urinary catheter. Review of the Urinary Elimination Care Plan intervention, revised on 06/19/2023, showed to secure the urinary catheter to facilitate urine flow and to always keep the bag off the floor. Observation on 12/26/2023 at 11:19 AM, showed Resident 82's catheter bag was hooked on the metal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain, label, and properly store nebulizer machine (breathing treatment) tubing, oxygen and/or suction machine (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) cannula/tubing for 3 of 4 residents (Residents 65, 85 & 10), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications. Findings included . Review of the facility's policy titled, Oxygen Administration, revised 01/02/2024, showed to change oxygen tubing and mask/cannula (nasal cannula -a device used to deliver supplemental oxygen) weekly and as needed if it becomes soiled or contaminated and to keep delivery devices covered in a plastic bag when not in use. Review of the facility's policy titled, Nebulizer Therapy, revised on 01/02/2024, showed staff was to Disassemble parts after each treatment. Rinse the nebulizer cup and mouthpiece with…

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

Based on observation, interview and record review, the facility failed to ensure licensed nurses had the appropriate competencies, skills set and proficiencies to administer medications for 3 of 5 nursing staff (Staff N, Staff O & Staff P), reviewed for competent nurse staffing. This failure placed the residents at risk for unmet care needs, potential medication errors, and adverse medication outcomes. Findings included . Review of facility's policy titled, Facility Assessment, dated February 2023, showed that based on the assessment of resident characteristics, the facility will determine what care/services and staff competencies are required to meet the needs of the residents. STAFF N Staff N, Registered Nurse (RN), was hired on 09/22/2023. Review of the undated employee record showed the facility did not complete the medication administration competency skills assessment for Staff N. Observation and interview on 12/29/2023 at 12:52 PM, showed Staff N, RN, prepared to give Resident 69's Geri Care Artificial Tears with ingredients: Glycerin 0.2%, Hypromellose 0.2% (chemical make-up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate monitoring was in place for psychotropic (mind altering) medication management for 1 of 5 residents (Resident 23), reviewed for unnecessary medications. This failure placed the resident at risk for unmet care needs, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's policy titled, Use of Psychotropic Medication, revised on 01/02/2024, showed that the effects of the psychotropic medications on a resident's physical, mental and psychological well-being will be evaluated on an ongoing basis, such as upon physician evaluation, during the pharmacist's monthly medication regimen review, during Minimum Data Set (an assessment tool) review, and in accordance with nurse assessments, and medication monitoring parameters consistent with clinical standards of practice. Resident 23 admitted to the facility on [DATE]. Review of the January 2024 Medication Administration Record (MAR) showed an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were provided education about COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccinations for 3 of 5 residents (Resident 5, 83 and 94), reviewed for COVID-19 immunizations. The failure to educate residents regarding the risks, benefits, and the potential side effects of COVID-19 vaccinations placed the residents at risk for having insufficient information to make informed decisions. Findings included . Review of the facility's policy titled, COVID-19 Vaccination implemented on 05/23/2023, showed that prior to offering the COVID-19 vaccine, residents, or the residents' representative will be educated regarding the risks, benefits and potential side effects associated with the vaccine in a form and manner that can be accessed and understood. RESIDENT 5 Resident 5 was admitted to the facility on [DATE]. Review of…

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