Stoney Point Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for four (Resident 7, Resident 79, Resident 85, and Resident 12) of 32 sampled residents by failing to:1.a. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 7, dated 4/3/2025 and completed on 7/1/2025.b. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 79, dated 4/30/2025 and completed on 7/1/2025.c. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 85, dated 4/9/2025 and completed on 7/1/2025.These deficient practices resulted in inaccurate medical documentation and had the potential for a decline in range of motion (ROM, full movement potential of a joint) in Residents 7, 79, and 85.2. Ensure Resident 7's diagnosis of anxiety was included in the diagnosis list in the resident's medical record.This deficient…

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 facility staff knocked and asked permission prior to entering a resident's room for two of two sampled residents (Resident 18 and 44). This deficient practice violated the residents' rights to be treated with respect and dignity, which had the potential to affect the residents' sense of self-worth and self-esteem.Findings:a. During a review of Resident 18's admission Record, the admission Record indicated the facility admitted the resident on 5/30/2025 with diagnoses including, Alzheimer`s Disease (a progressive disease that destroys memory and other important mental functions) and lack of coordination.During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool) dated 6/6/2025, the MDS indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses. The MDS indicated that Resident 18 was totally dependent on…

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

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of one sampled resident (Resident 25). This deficient practice had the potential to delay the provision of services and the resident's needs not being met.Findings:During a review of Resident 25's admission Record, the admission Record indicated the facility admitted the resident on 9/23/2024 with diagnoses that included dysphagia (difficulty swallowing) and schizophrenia (mental disorder in which people interpret reality abnormally). During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool) dated 3/27/2025, the MDS indicated Resident 25's cognition (a mental process of acquitting knowledge and understanding) was impaired. The MDS indicated Resident 25 required supervision with activities of daily living (ADLs - activities related to personal care). During a concurrent observation and interview on 6/30/2025 at 10:07 a.m., with Certified…

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 copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) was kept in the resident's medical chart and easily retrievable for two of eight sampled residents (Resident 40 and 81).This deficient practice had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care.Findings: a. During a review of Resident 40’s admission Record, the admission Record indicated that the facility admitted the resident on 7/5/2025, with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 40’s Minimum Data Set (MDS – a resident assessment tool) dated 5/1/2025, the MDS indicated that Resident 40 could understand others…

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 a complete baseline care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) within 48 hours of a resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) for one of two sampled residents (Resident 81). This deficient practice had the potential for Resident 81 to not receive appropriate care and treatment in the facility. Findings:During a review of Resident 81's admission Record, the admission Record indicated that the facility originally admitted the resident on 1/3/2025 and readmitted the resident on 6/17/2025, with diagnoses including dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), obstructive uropathy (a blockage in the urinary tract that prevents urine 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 develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for two of four sampled residents (Resident 75 and 114) by failing to: 1. Develop a care plan addressing Resident 75's use of olanzapine (medication used to treat schizophrenia (mental disorder in which people interpret reality abnormally) and bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). 2. Develop a care plan addressing Resident 114's use of amphetamine-dextroamphetamine (medication used to treat attention-deficit/hyperactivity disorder [ADHD - a chronic condition including attention difficulty, hyperactivity, and impulsiveness]). These deficient practices had the potential to result in failure to deliver the necessary…

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 update and revise a resident`s dental care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident`s upper dentures went missing for one of three sampled residents (Resident 69). This deficient practice had the potential to result in Resident 69 receiving inadequate care and services. Findings:During a review of Resident 69's admission Record, the admission Record indicated that the facility originally admitted the resident on 5/12/2022 and readmitted the resident on 12/3/2024, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type two diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool) dated 4/30/2025, the MDS indicated that the resident`s cognitive skills (brain's ability 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 interview and record review, the facility failed to:1. Ensure fall risk assessments were completed accurately for one of ten sampled residents (Resident 7).This deficient practice had the potential to place Resident 7 at an increased risk of falling.2. Ensure a fall risk assessment was completed for one of ten sampled residents (Resident 119) after the resident`s fall on 6/25/2025. This deficient practice placed Resident 119 at an increased risk for recurrent falls and injuries. Findings: a. During a review of Resident 7’s admission Record, the admission Record indicated the facility admitted the resident on 7/20/2020 with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood), lack of coordination, and mild cognitive impairment (a decline in mental abilities, including thinking, learning, remembering, and decision-making) of unknown etiology (the cause of a disease or abnormal condition). During a review of Resident 7’s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by failing to ensure the dialysis center recorded a resident's post dialysis weight (the weight after fluid is removed during the dialysis treatment) on 6/25/2025.This deficient practice had the potential for Resident 46 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Findings:During a review of Resident 46's admission Record (or face sheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the patient was admitted to the facility on [DATE] 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 interview and record review, the facility failed ensure resident's drug regimen was free from unnecessary drugs by failing to adequately monitor potential adverse effects of amphetamine-dextroamphetamine (stimulant medication to treat ADHD [differences in how the brain develops and works causing problems with a person's attention, ability to sit still, and practice self-control]) for one of one sampled resident (Resident 114). This deficient practice had the potential for adverse effects including psychosis (hallucinations, delusions, paranoia, aggression, hostility) and heart issues such as fast heartbeat and hypertension.Findings:During a review of Resident 114's admission Record, the admission Record indicated the facility admitted Resident 114 on 4/15/2025 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN-high blood pressure), and unspecified atrial fibrillation (an irregular and often very rapid heart rhythm in the upper part of the heart). During a review of 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.

Based on observation, interview, and record review, the facility failed to accommodate a resident's food allergies and preferences for one of six residents (Resident 7) investigated under nutrition by:1. Failing to document Resident 7's allergy to eggs on the tray ticket (a document that accompanies a meal tray with essential information about the meal and the resident receiving it).2. Failing to ensure Resident 7 received a substitution for breakfast when eggs were not served.These failures placed Resident 7 at risk of:1. Being served eggs and having a reaction such as a rash, hives, diarrhea, vomiting, dehydration (occurs when your body loses too much water and other fluids), and/or anaphylactic shock (severe allergic reaction including closure of airways). 2. Not receiving the needed nutrition, they require. Findings: 1. During a review of Resident 7’s admission Record, the admission Record indicated the facility admitted the resident on 7/20/2020 with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the provision of medically-related social services to meet one of five sampled residents (Resident 4) needs by failing to follow up the status of Resident 4's missing rollator walker (a mobility aid designed for residents who need support while walking) and ensure timely replacement of Resident 4's missing rollator walker. On 10/26/2024, Resident 4 was discharged from the facility without providing Resident 4's rollator walker. This deficient practice placed Resident 4 at risk for health and safety impacts such as impairing Resident 4's ability to walk safely leading to fall and injury, reduced mobility (movement), and loss of independence which can lead to decreased self-esteem (confidence in one's own abilities or worth) and a sense of helplessness. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 3/27/2024 with diagnoses that included systemic lupus erythematosus…

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 one of three sampled residents (Resident 1) discharge planning process included, providing Resident 1 and Resident 1 ' s Responsible Party (RP) 1 with information including services and quality measures (quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems) of the accepting skilled nursing facility Resident 1 was transferred to. This deficient practice had potential for decreased quality of care, decreased quality of life and continuity of care. Findings: During a review of Resident 1 ' s admission Record (facesheet) dated 2/16/2025, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), pneumonia (an infection/inflammation in the lungs), cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), dementia (a progressive state 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 interview and record review, the facility failed to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) verification from a resident responsible party (RP - a person who makes medical decision for a resident) for one of four sampled residents (Resident 1) regarding the administration of antipsychotic (a medication used to treat psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] related symptoms and conditions) medication known as Olanzapine (a medication used to treat and manage psychosis) from Resident 1's RP. This deficient practice resulted in the facility administering a psychotropic (a medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication to Resident 1 without informed consent and denied Resident 1's RP the right to make informed treatment…

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 a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for seven of 30 sampled residents (Resident 34, 117, 65, 7, 72, 59, and 27) by failing to: 1. Develop a care plan addressing Resident 34, 117, and 65's insulin (hormone that regulates the level of glucose [sugar] in the blood) use. 2. Develop a care plan addressing Resident 7's use of psychotropic medications (medications capable of affecting the mind, emotions, and behavior). 3. Develop a care plan addressing Resident 72's diagnosis of viral hepatitis C (a viral infection that causes liver inflammation (swelling). 4. Develop a care plan addressing Resident 59 and Resident 27's diagnosis of urinary tract infection (UTI, an infection in any part of the urinary system) and antibiotic (medications that fight bacterial infections) use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure medication administration was supervised and medications were not left at bedside for one of 30 sampled residents (Resident 7). This deficient practice had the potential to allow Resident 7 to miss a dose of medications and allow other residents to consume the medications. 2. Ensure a resident's bed was positioned in the lowest position while the resident was in bed, as ordered by the physician, for one of 30 sampled residents (Resident 22). This deficient practice had the potential to place the resident at increased risk of sustaining a fall with injuries. 3. Ensure one of one resident (Resident 118), who was at high risk for falls, had bilateral landing mats placed in her room next to her bed as ordered by physician. This deficient practice had the potential to place the resident at increased risk of sustaining an injury. Findings: 1. A review of Resident 7's admission Record indicated the facility readmitted the resident on…

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

Based on interview and record review, the facility failed to ensure licensed nurses documented that they attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid medications (medication used to treat moderate to severe pain) on multiple days for one of 30 sampled residents (Resident 29). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from opioid pain medication. Findings: A review of Resident 29's admission Record indicated the facility admitted the resident on 5/3/2024 with diagnoses including polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness) and chronic pulmonary edema (a condition that occurs when fluid builds up in the lungs over time, making it difficult to breathe). A review of Resident 29's Minimum Data…

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 resident was free from significant medication error by failing to administer several medications as ordered by the physician for one of 30 sampled residents (Resident 7). This deficient practice resulted in Resident 7 receiving her medications late and had the potential to result in Resident 7 missing a dose of her medications. Findings: A review of Resident 7's admission Record indicated the facility readmitted the resident on 4/30/2024 with diagnoses that included end stage renal disease (ESRD- a condition in which the kidneys [organs that remove waste products from the blood and produce urine] no longer function normally). A review of Resident 7's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], indicated Resident 7 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). 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 2. A review of Resident 7's admission Record indicated the facility readmitted the resident on 4/30/2024 with diagnoses that included end stage renal disease (ESRD- a condition in which the kidneys [organs that remove waste products from the blood and produce urine] no longer function normally). A review of Resident 7's MDS dated [DATE], indicated Resident 7 had severely impaired cognition. A review of Resident 7's Order Summary Report, dated 7/25/2024, indicated an order for oxygen inhalation at two (2) liters per min (LPM, unit of measurement) via nasal cannula as need for shortness of breath and comfort with a titration (adjusting the dose of a medication) of three (3) to five (5) liters as needed, ordered 5/8/2024. During a concurrent observation and interview on 7/22/2024 at 10:25 a.m., with Registered Nurse 1 (RN 1) in Resident 7's room, observed Resident 7's oxygen concentrator (medical device that gives oxygen) humidifier and nasal cannula were both unlabeled with the nasal cannula around the oxygen…

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' call lights (a device used by patients to call for assistance from hospital staff) were within reach for two of 30 sampled residents (Resident 27 and 28) . This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being. Findings: a. A review of Resident 27's admission Record indicated the facility admitted the resident on 1/27/2022 with diagnosis of chronic obstructive pulmonary disease (COPD, a common lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), difficulty in walking, and lack of coordination. A review of Resident 27's History and Physical (H&P, a comprehensive assessment of a resident and their problem) dated 6/5/2023, indicated that does not have the capacity to understand and make…

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 Vocational Nurse 3 (LVN 3) provided privacy to a resident before administering medications via gastrostomy tube (g-tube - a tube that's surgically inserted through the abdomen and into the stomach used for medication and nutrition) for one of 30 sampled residents (Resident 62). This deficient practice violated the resident's right to privacy. Findings: A review of Resident 62's admission Record indicated the facility admitted the resident on 11/2/2019 with diagnoses including aphasia (a language disorder that makes it difficult to understand and express language, as well as read and write), hemiplegia (partial or complete paralysis on one side of the body) and hemiparesis (mild loss of strength or paralysis on one side of the body), and encounter for attention to gastrostomy (a surgical procedure that creates an opening in the skin and into the stomach to insert a feeding tube). A review of Resident 62's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated…

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

Based on observation, interview, and record review, the facility failed to follow safe food handling practices by failing to discard two bags of hotdog buns 12 days past their best by date. This deficient practice had the potential to place 24 out of 121 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a kitchen observation on 7/22/2024 at 8:11 a.m., with Kitchen Supervisor 1 (KS1), observed two bags of hotdog buns containing 12 buns in each bag with a Best By date of 7/10/2024. KS 1 stated he is going to discard the hotdog buns. KS 1 further stated that the hotdog buns are no longer safe for the residents to consume if past its Best By date. KS 1 stated that hotdog buns may already have mold and if eaten could result to foodborne illnesses. A review of the facility's policy and procedure titled, Food Receiving and Storage, last reviewed on 1/16/2024, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to follow the facility ' s policy related to smoking for two of five sampled residents (Resident 3 and 4) when they allowed Resident 3 to share a cigarette with Resident 4. This deficient practice has the potential for Resident 4 to be place at risk for accidents such as burns. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the Resident 3 on 1/15/2024 with diagnosis that included Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), and respiratory disorders (diseases related to the lungs). A review of Resident 3 ' s History and Physical dated 1/16/2024 indicated that Resident 3 has the capacity to understand and make decisions. A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/22/2024, indicated that Resident 3 had moderately impaired cognition (the mental action or…

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 that one of two sampled residents (Resident 6) was free from physical restraint (the use of a manual hold or device to restrict freedom of movement of all or part of a resident ' s body) when facility staff placed a lap buddy (cushioned device that fits in a wheelchair and assist with reminding a person not to get up by themselves) on the resident ' s wheelchair without a restraint assessment, consent ( when a resident gives permission before they receive any type of medical treatment), and physician ' s order. This deficient practice resulted in the absence of continued assessment and monitoring of a restraint, and had the potential to result in an increased risk for complications of restraint use such as decline in functioning, injury, entrapment (event in which a resident is caught, trapped or entangled in a space where they are being restrained), or death caused by physical restraints. Findings: A review of Resident 6 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for two of five sampled residents (Resident 1 and 6) by failing to: 1. Ensure a care plan was created for a positive Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms) test for Resident 1. 2. Ensure a care plan was created addressing Resident 6 being identified as a high fall risk . This deficient practice had the potential to result in a delay in or lack of delivery of care and services. Findings: 1. A review of Resident 1 ' s admission record indicated the facility originally admitted the resident on 12/13/2019 and readmitted the resident on 6/15/2023 with diagnoses including Cerebral infarction (CVA or stroke, when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts)), COVID-19 and aphasia (language disorder…

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 information and assistance with formulating an advance directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), for four (Residents 6, 85, 19, and 114) out of 13 sampled residents investigated for advance directives. This deficient practice violated residents' and/or their representatives' right to be fully informed of the option to formulate an advance directive and to cause conflict due to lack of communication regarding residents' wishes about their medical treatment. Findings: a. A review of the admission record indicated Resident 6 was admitted to the facility, on 11/23/2021, with diagnoses including muscle weakness, dysphagia (difficulty swallowing), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar). A review of the Minimum Data…

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's Interdisciplinary Team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) failed to ensure that care plans were reviewed for two out three residents (Resident 47 and 52) investigated under the care area of Care Plan Timing and Revision, by failing to: 1. Ensure care plans were revised timely when Resident 47 started receiving hospice (end of life care) services on 11/10/2021. 2. Ensure care plans were revised timely for the use of Zyprexa (an anti-psychotic - medication used to treat severe agitation associated with certain mental/mood conditions) and Remeron (an antidepressant - a medication used primarily to treat depression) for Resident 52. These deficient practices had the potential to affect the provision of necessary care and services for Residents 47 and 52. Findings: a. A review of the admission record indicated Resident 47 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nurses assessed a resident's arteriovenous shunt (AV shunt - abnormal connections between coronary arteries and a compartment of the venous side of the heart) before and after dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) treatments for one (Resident 81) out of one sampled resident investigated for dialysis. This deficient practice had the potential to place the resident at risk for a delay in detecting if the resident had a non-functioning AV shunt and a delay in detecting complications including infections and bleeding. Findings: A review of Resident 81's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (when the kidneys are damaged and can't filter blood the way they should). A review of Resident 81's Minimum Data Set (MDS - a standardized assessment 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.

Based on observation, interview, and record review, the facility failed to store food and supplies in a safe manner by failing to ensure a scoop was not left in the all- purpose flour container. This deficient practice had the potential to result in contamination after repeated use without washing and cleaning the scoop that could lead to harmful bacteria growth that can cause foodborne illnesses (illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview with the Dietary Aide 1 (DA 1) on 02/28/2022 at 07:57 a.m., observed a plastic container containing powdery substance. Upon closer inspection, observed a stainless scoop partly buried in the powdery substance. According to DA 1, the content of the container was an all-purpose flour, and the scoop should not be left inside the container since the handle always comes in contact with the hands of the staff when they use the scoop to obtain flour for cooking. According to DA 1, repeated use without cleaning or washing the scoop could result to contamination of the scoop…

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 an infection prevention and control program by: 1. Failing to ensure the gastrostomy (a surgically placed device used to give direct access to the stomach for feeding, hydration, or medication) irrigation syringe (syringe designed for delivering tube feeding, water, and medications) was changed every 24 as indicated in the facility policy and procedure for two (Resident 27 and Resident 111) of three sampled residents reviewed for tube feeding. 2. Failing to label the nebulizer (a machine that creates a mist out of liquid medication) tubing with the date it was last changed for one (Resident 27) of three sampled residents reviewed for respiratory care. 3. Failing to ensure the resident's oxygen tubing was kept off the floor for two (Resident 82 and Resident 96) out of three sampled residents reviewed for respiratory care. 4. Failing to ensure the resident's oxygen tubing was dated for one (Resident 96) of three sampled residents…

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 obtain an informed consent from the resident and/or resident representative for the use of lap cushion/buddy (an inflatable cushion that snugs into the wheelchair frame itself) which restricts the resident`s freedom of movement, for one (Resident 6) of one resident reviewed for use of restraints. This deficient practice violated the resident's right to be informed from any restrictions such as restraints. Findings: A review of admission record indicated Resident 6 was admitted to the facility, on 11/23/2021, with diagnoses including muscle weakness, dysphagia (difficulty swallowing), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of the Minimum Data Set (MDS- a standardized assessment and screening tool), dated 11/30/2021, indicated Resident 6's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were accessible by residents by: 1. Failure to ensure the toilet shared by Residents 16, 35, 62, and 66 had a cord attached to the call light (a device used by a patient to signal his or her need for assistance from professional staff). 2. Failure to ensure Resident 106's call light was within reach while in bed for one out of six sampled residents investigated for accommodation of needs. These deficient practices placed the residents at risk for not receiving the necessary assistance to promote residents' safety. Findings: a. During a concurrent observation and interview, on 02/28/2022 at 10:06 a.m., with Licensed Vocational Nurse 1 (LVN 1), the call light in the bathroom in between rooms [ROOM NUMBERS] were observed without a cord for residents to pull to receive assistance from staff. LVN 1 stated Residents 16, 35, 62, and 66 were using the toilet in the bathroom. LVN 1 stated it was important for the call light 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 interview and record review, the facility failed to provide the resident and the resident representative written bed hold notice at the time of transfer to the general acute care hospital (GACH) for one of one sampled resident (Resident 87) investigated under care area for hospitalization. This deficient practice could lead to a transfer of the resident to another skilled nursing facility without the responsible party's acknowledgement. Findings: A review of the admission record indicated Resident 87 was admitted to the facility, on 1/21/2022, with diagnoses that included acute respiratory distress (a condition that causes fluid to build up in your lungs and deprives your organs of oxygen), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (high blood pressure), and dysphagia (difficulty swallowing…

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 Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) for significant change in status was completed within the required time frame for one of one sampled resident (Resident 47) when resident started receiving hospice services (end of life care). This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: A review of the admission record indicated Resident 47 was admitted to the facility, on 3/27/2019, with diagnoses including vascular dementia (a condition caused by conditions such as stroke that disrupt blood flow to the brain and lead to problems with memory, thinking, and behavior), psychosis (a term used to describe when a person interprets or perceives reality in a different way to those around them), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities),…

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's admission and discharge Minimum Data Sets (MDS - a standardized assessment and care screening tool) were transmitted within 14 days after the assessment reference date (ARD - the specific end point of look-back periods in the MDS assessment process), for one (Resident 5) out of one sampled resident investigated for resident assessment. This deficient practice had the potential to result in delayed services for the resident. Findings: A review of the admission record indicated Resident 5 was admitted to the facility, on 09/04/2021, with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of the Centers for Medicare and Medicaid Services (CMS - a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program) Submission Report indicated that…

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: 1. Develop and implement a CP (care plan - helps nurses and other care team members organize aspects of patient care according to a timeline) that would address the care needs of a resident on enteral feeding (a way of delivering nutrition directly to your stomach) via G-tube (gastrostomy tube - inserted through the belly that brings nutrition directly to the stomach), for one of two sampled resident (Resident 21) investigated under the care area comprehensive care plans. 2. Implement the care plan addressing the residents' need for assistance with activities of daily living (ADL- term used in healthcare to refer to people's daily self-care activities) for one of two sampled residents (Resident 83) investigated under the care area comprehensive care plans. These deficient practices have the potential for Residents 83 and 21 to lack the delivery of necessary care and services without an appropriate plan of care. Findings: a. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 2 (LVN 2) did not leave medications unattended at the resident's bedside during the medication administration observation for one (Resident 114) out of four sampled residents observed for medication administration. This deficient practice had the potential to either cause a medication administration error. 2. Ensure LVN 2 administered potassium chloride (used to prevent or to treat low blood levels of potassium) with food and a full glass of water as prescribed by the physician for one (Resident 114) out of four sampled residents observed for medication administration. This deficient practice had the potential to cause stomach irritation to the resident. Findings: A review of the admission record indicated Resident 114 was admitted to the facility, on 05/01/2017 and readmitted on [DATE], with diagnoses that included Alzheimer's disease (the most common cause of dementia, a general term for memory loss…

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 one of three sampled residents (Resident 47) received treatment and care in accordance with professional standards of practice by failing to: 1. Ensure an Interdisciplinary Team (IDT- a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a patient or group of patients) meeting was held when Resident 47 started receiving hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life) services. 2. Ensure that facility care plan and hospice care plan were integrated and collaborated when Resident 47 started receiving hospice services. These deficient practices had the potential to negatively affect the resident's well-being and the provision of necessary care and services when the resident started receiving hospice services. Findings: A review of Resident 47's Face Sheet indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the as needed (PRN) order oxygen administration included the flow rate (amount of oxygen being delivered to the body) of oxygen in liters and failed to ensure nursing staff document the reason for PRN oxygen administration for one (Resident 27) of two sampled residents reviewed for respiratory care. This deficient practice could lead to adverse effects (any unexpected or dangerous reaction to a drug) due to unnecessary oxygen administration or higher than necessary rate of oxygen administration leading to a negative impact on the resident's overall health. Findings: A review of Resident 27's Face Sheet indicated the resident was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nurses provided nonpharmacological (interventions that do not involve the use of medications) interventions prior to administering pain medication to two (Residents 19 and 181) out of two sampled residents investigated for pain management. This deficient practice had the potential to increase the risk of the residents experiencing adverse side effects (any unexpected or dangerous reaction to a drug) from pain medication. Findings: a. A review of Resident 19's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included a fractured (broken bone) rib. A review of Resident 19's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/19/2022, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for bed…

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

Based on observation, interview and record review, the facility failed to ensure staffing information was posted and updated in the lobby on a daily basis. This deficient practice resulted in the total number of staff and the actual hours worked by the staff not readily accessible to residents and visitors. Findings: During a concurrent observation and record review on 2/28/2022 at 7:35 a.m., observed a posting of the Census and Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) at the lobby, indicated the date of 2/25/2022 and a resident census of 118. During an observation on 3/2/2022 at 7:26 a.m., the DHPPD posted in the facility lobby was not changed or updated and indicated a date of 2/28/2022. During an interview on 3/3/2022 at 1:58 p.m., the Director of Staff Development (DSD) stated the Staffer is responsible for posting the DHPPD in the lobby and at the Nurses' Station daily. The DSD validated that the staffing information was not updated upon showing photo of the posting in the lobby dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. A review of Resident 47's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses including but not limited to vascular dementia (a condition caused by conditions such as stroke that disrupt blood flow to the brain and lead to problems with memory, thinking, and behavior), psychosis (a term used to describe when a person interprets or perceives reality in a different way to those around them), and anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 47's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 12/31/2021, indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated the resident did not receive an anti-anxiety medication during the 7-day look back period (time frame for observation). A review of Residents 47's…

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