Linden Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents environment remained free of accident/hazards with: A) a resident that required a smoking apron for safety when smoking for 1 of 2 residents (Resident 29) reviewed for accident/hazard of smoking, B) the securement of compressed oxygen cylinder storage for 1 of 2 storage rooms (East/West storage room) reviewed for accident/hazards of oxygen cylinder storage, and C) that toxic cleaning chemicals were safely stored away from residents for 2 of 3 hallways (East/West and Central Hall) reviewed for accidents/hazards of chemicals. This failure placed residents at an increased risk for avoidable accidents, significate injury, and unmet care needs. Findings included . Review of the facility's policy titled, Smoking Policy for Independent and Supervised, revised December 2017 showed that residents who wished to smoke would be assessed for their risks with smoking and the ability to smoke safely. Residents who did not meet 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.

<Kitchen> An observation and interview on 10/24/2024 at 12:20 PM, showed Staff O, Cook, and Staff N, Dietary Aide, starting the lunch meal serve out, 20 minutes after the posted lunch meal start time. The first cart of lunch trays was sent out of the kitchen at 12:28 PM, the second at 12:36 PM, the third at 12:45 PM, and the fourth at 12:54 PM. At 1:01 PM, Staff O informed Staff M, Dietary Manager, that there were not enough pellet inserts (a warmed disc placed in the base of a plate holder to retain heat) for the plate warmers. There were six lunch meals that were placed in the meal tray cart that did not have pellet inserts, including the surveyor test tray. Staff M stated they frequently ran out of silverware and pellets for the warmers. They stated they go out on the meal trays but don't come back. At 1:06 PM, the final meal tray cart was sent out, one hour and six minutes after the posted mealtime. During a continued observation and interview on 10/24/2024 at 1:14 PM, showed a pureed meal, the noodles were a translucent, white, gel-like substance, with a scoop of a brown pureed…

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 periodic testing of sanitizing agents used for proper sanitation of food preparation surfaces in accordance with professional standards for food service safety, appropriate labeling of open foods, and that food delivery carts were clean, for 1 of 1 kitchen reviewed for safe food service. This failure placed residents, staff, and visitors that ate from the facility's kitchen at risk for food borne illnesses and the spread of infectious diseases. Findings included . Review of the policy titled, Food Preparation and Service, dated 11/2022, showed food and nutrition services staff would prepare, distribute, and serve food in a manner that complied with safe food handling processes. Appropriate measures used to prevent cross contamination (the spread of chemical or disease-causing organisms transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that were not adequately cleaned) included using sanitizing towels or cloths for wiping surfaces in a container filled with an…

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

Based on observation, interview, and record review, the facility failed to ensure residents that required assistance with eating received a dignified meal service, related to timely assistance with meals, for 2 of 4 residents (Residents 14 and 3) reviewed for dignity. This failure placed the residents at risk for unmet care needs and a deterioration in their quality of life. Findings included . <Resident 14> Review of the resident's medical record showed they were admitted to the facility with diagnoses including dementia (a progressive disease that destroys the memory and other important mental functions), dysphasia (impaired ability to swallow) and legal blindness. Resident 14's comprehensive assessment, dated 08/28/2024, showed the resident was severely cognitively impaired and required substantial assistance (a considerable amount) with eating. Review of Resident 14's care plan, dated 09/03/2024, showed the resident's legal blindness and cognition status was the reason they required substantial assistance from staff with their meals. During an observation on 10/22/2024 from…

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 review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were corrected on/after residents admission to the facility and had the required Level II referral sent if residents had a positive Level I PASARR for 2 of 8 residents (Resident 29 and 56) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-admission Screening and Resident Review (PASARR or PASRR) Level I Screening Process, dated 07/06/2024, showed that nursing facilities will ensure residents with a positive Level I PASARR screen have been evaluated by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that addressed the resident's goals and needs, that involved the resident and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 1 of 3 residents (Resident 264) reviewed for discharge planning process. The failure to develop and implement a discharge plan consistent with the resident's needs and expressed discharge goals, placed the resident at risk for decreased self-worth and dissatisfaction with their living situation. Additionally, the facility failed to ensure a safe discharge when 1 of 2 residents (Resident 61) discharged against medical advice (AMA) with a peripheral inserted central catheter line [(PICC) a thin, flexible tube that is inserted into a vein in the arm and threaded into a large vein above the heart used to deliver fluids and medications]. This failure placed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care of their type two diabetes mellitus (a disease that causes inadequate control of the body's blood levels of sugar, which can lead to abnormally high or low levels of the body's blood sugar) in accordance with professional standards of practice for 1 of 2 residents (Resident 218) reviewed for insulin (a medication that assists in control of blood sugar levels) therapy. This failure placed residents at an increased risk for unmet care needs, emergent situations, and poor health outcomes. Findings included . Review of a policy titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, showed blood glucose (sugar) monitoring of diabetic residents were needed to detect hyperglycemia (high levels of blood sugar in the body, greater than 150 milligrams/deciliter [mg/dL, units of measure]) and hypoglycemia (low levels of blood sugar in the body, less than 70 mg/dL)…

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 identify and utilize an implanted bladder stimulator device [(InterStim) - an implantable device that treats urinary incontinence and overactive bladder by sending electrical pulses to the sacral nerves] used to treat urinary incontinence for 1 of 2 residents (Resident 5) reviewed for urinary incontinence (a loss of bladder control or involuntary urination). This failure placed the resident at risk for poor self-esteem related to dignity, skin impairments, continued urinary incontinence, and other health complications. Findings included . Review of the Medtronic InterStim guidance titled, Sacral Neuromodulation (the use of electrical or chemical stimulation to change nerve activity), dated 10/2024, showed the InterStim system was an implanted neurostimulator (a device that uses electrical stimulation to treat neurological disorders). The leads (wires) from the implanted device stimulate the sacral nerves that control normal bladder and bowel function.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma informed care, complete with identified experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience) for 1 of 4 residents (Resident 29) reviewed for trauma informed care. This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Review of the policy titled, Trauma Informed Care, dated 08/01/2024, showed, Trauma-informed care is an approach aimed at identification of individuals with a trauma history and the development of care approaches that are sensitive to the individual needs . The policy showed identifying potential triggers and making modifications to care approaches and strategies would be a focus to order to avoid…

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 a medication error rate of less than five percent for 2 of 5 residents (Residents 218 and 1) observed during 27 medication administration opportunities that resulted in an error rate of 7.41 percent. This failure placed the residents at risk of not receiving the full therapeutic effect of the medication and potential adverse side effects. Findings included . Review of the Basaglar KwikPen (a pre-filled disposable device containing an insulin medication) instructions for use, dated 11/2023, showed the insulin pen needed to be primed (removing air from the needle and cartridge that may have collected during normal use) before each injection. If the pen was not primed before each injection, too much or too little insulin could be delivered. Review of a policy titled, Medication Administration, dated 01/2023, showed check expiration date on package/container .no expired medication will be administered to a resident. <Resident 218>…

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 interview, the facility failed to properly dispose of kitchen refuse for 1 of 1 kitchen, reviewed for refuse disposal. This failure placed the facility at risk for attracting insects, rodents, and an unsanitary environment. Findings included . During an observation on 12/24/2024 at 12:38 PM, showed a fly in the kitchen, walking on the lipped plates that were being used during serve out. At 12:42 PM, a second fly was noted resting on the plates. An observation on 10/28/2024 at 12:41 PM, showed two black trash bags containing kitchen food garbage, on a cart located outside of the emergency exit of the kitchen/laundry hallway with snow peas scattered on the ground. There were flies, bees, and gnats swarming around the trash bags and snow peas. During an interview on 10/29/2024 at 12:47 PM, Staff O, Cook, stated they put the kitchen trash outside the door until later. During an interview on 10/29/2024 at 12:55 PM, Staff M, Dietary Manager, stated the process for removing trash from the kitchen included taking it to the dumpster right away and not leaving it…

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 a resident had the cognitive capacity to understand the nature and implication of entering into a binding arbitration agreement used to settle disputes without a jury trial for 1 of 3 residents (Resident 39) reviewed for arbitration. This failure placed the resident at risk for a lack of understanding of the legal contract they had signed and their right to make a choice for a jury trial in the event of a dispute with the facility. Findings included . <Resident 39> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including, congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and bipolar disorder (a mental disorder that causes changes in mood and energy). Review of the comprehensive assessment, dated 10/09/2024, showed the resident had severe cognitive impairment with their Brief Interview of Mental Status (BIMS, a numerically scored…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of potential abuse and/or neglect to their State Agency, for 1 of 5 residents (Residents 13), reviewed for abuse/neglect. This failure placed the resident at risk for unidentified abuse/neglect, and the potential continued exposure to abuse and/or neglect. Findings included . Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, revised January 2023, showed that it was the policy of the facility to report allegations of abuse to appropriate reporting authority, that all staff members were considered mandatory reporters and were required to report their State Agency. <Resident 13> Review of the resident medical records showed they were admitted to the facility on [DATE] with diagnoses including an infection in the left leg, anxiety, depression, and a developmental disability (a disorder that includes intellectual disabilities or learning problems and unique…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to conduct a thorough investigation into an allegation of abuse for 1 of 2 residents (Resident 13), reviewed for abuse and neglect. This failure placed the resident at risk for unidentified abuse, unmet care needs, and the potential continued exposure to abuse and/or neglect. Findings included . Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, revised January 2023, showed that all allegations of abuse were to have a thorough investigation completed and that administrative personnel immediately remove staff member involved in said incident from their duties. The staff member is removed from the center until administrative personnel can complete a through investigation of reported incident. <Resident 13> Review of the resident medical records showed they were admitted on [DATE] with diagnoses including an infection of the left leg, anxiety, depression, and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet the requirements for a facility-initiated discharge for 1 of 2 residents (Resident 53), reviewed for discharge requirements. Resident 53 was not allowed to remain a resident in the facility after requesting a therapeutic leave to visit their sick spouse. This failed practice placed the resident at risk for homelessness, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy titled Notice of Transfer or Discharge, dated 03/2019, showed a facility-initiated discharge was a discharge that the resident objects to, did not originate through a resident's verbal or written request, and/or was not in alignment with the resident's stated goals for care and preferences. <Resident 53> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, and a broken upper arm. The 07/18/2023 comprehensive assessment showed the resident required…

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 notice to the resident and their representative of the facility's intention and justification for the discharge of 1 of 2 residents (Resident 53) reviewed for facility-initiated discharges. Additionally, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes). This failed practice disallowed the resident and/or their representative an opportunity to fully understand the rationale and resident rights associated with the discharge. This failure also placed the resident at risk for diminished protection, lack of access to an advocate that could inform them of their options and rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to transfer or discharge. Findings included . Review of the facility policy titled, Notice of Transfer…

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 bed-hold notice at the time of transfer or within 24 hours of transfer to the hospital for 2 of 3 Residents (Residents 11 and 205), reviewed for hospitalization. This failure placed the residents and/or their representative at risk for a lack of knowledge regarding their right to hold their bed while hospitalized . Findings included . Review of the facility's policy titled, Bed Hold, dated October 2016, showed .upon transfer to offer the resident and responsible part the option to hold the bed .upon transfer or discharge the nursing department will provide the resident and responsible party a copy of the bed hold policy, and a bed hold form needed to be filled out whether a resident wanted to secure their bed or not. Additionally, .Social Service Director will contact the responsible party to notify them of facility policy and obtain decision (to hold the resident bed or not), which would be within 24 hours. <Resident 11> Review of…

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

Based on observation, interview, and record review, the facility failed to prepare palatable meals for 4 of 9 sample residents (Residents 3, 6,11, and 26) reviewed for food service. This failure placed the residents at risk for a diminished dining experience, dissatisfaction with food served, and a potential for less than adequate nutritional intake leading to weight loss. Findings included . <Dining Observation> <Resident 3> Review of the medical record showed the resident was alert and oriented with diagnoses of diabetes (when the body cannot process insulin and blood sugar is high) and kidney disease. The resident chose to eat in their room. During an interview and concurrent observation on 09/18/2023 at 12:35 PM, the resident's noon meal was served. The resident told staff to take it away because it was cold. During an observation on 09/19/2023 at 12:30 PM, the resident's lunch was served. The resident refused the meal due to the unappetizing taste and cold temperature of the food. During an interview and observation on 09/21/2023 at 1:11 PM, the resident stated the lunch was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to serve preferred foods and meal substitutions for 4 of 6 residents (Residents 3, 9, 20, and 32) reviewed for food and nutrition services. This failure placed the residents at risk for decreased dietary intake, unintended weight loss, and a diminished quality of life. Findings included . <Resident 3> Review of the medical record showed the resident had diagnoses of diabetes (when the body cannot process insulin and blood sugar is high), heart disease, kidney disease and a diabetic ulcer to the heel of their left foot (a sore that develops on the foot or heel due to a loss of sensation). During an interview and concurrent observation on 09/18/2023 at 12:35 PM, the resident noon meal consisted of breaded chicken, rice, and banana pudding. The resident told staff to take it away because it was cold and had too many carbohydrates (food containing a lot of sugars and starches). Staff did not offer an alternative menu to the resident. The 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 interview and record review the facility failed to provide Specialized Rehabilitative (Rehab) Services according to physician's orders for 1 of 2 residents (Resident 41) reviewed for therapy services. The failure to provide speech therapy (ST) services to Resident 41 placed them at risk for a decline in physical and functional mobility, deterioration of muscle strength and a potential delay in the resident's progression towards regaining their normal eating ability. Findings included . <Resident 41> Review of the resident's medical records showed that they were admitted on [DATE] with diagnoses including stroke, brain bleed, dysphagia (swallowing complications), aphasia (the loss of the ability to understand or express speech), and a percutaneous endoscopic gastrostomy tube (PEG Tube, a feeding tube through the skin into the stomach that provided a means for nutrition when a resident swallowing ability was not adequate). Review of the resident's most recent comprehensive assessment, dated 07/25/2023,…

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 appropriate personal protective equipment (PPE - enhanced prevention strategies to prevent spread of disease) including the use of an N95 mask (a respiratory protective device designed to achieve a very close facial fit and filtration of airborne particles), gown, gloves, and eye protection/face shield during facility wide testing for COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of that or smell, and in severe cases difficulty breathing that could result in severe impairment or death) for 1 of 1 resident (Resident 4), reviewed for COVID-19 testing. In addition, the facility failed to ensure infection control practices for 2 of 2 residents (Resident 4 and 9) were implemented related to hand hygiene and glove changes between dirty and clean tasks (after touching the resident and/or the resident's…

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