Mission Valley Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that continued nutritional care and services were provided to one of 20 sampled residents (Resident 68) when Resident 68, who had a weight loss of 11.2 pounds which yielded 11.8% weight loss from 4/6/26 to 5/1/26, was not reweighed after 5/1/26 for a total of 20 days (pounds or lbs. is a form of measurement which is also used to measure body weight).This deficient practice had the potential to result in Resident 68's further unplanned weight loss. During a review of Resident 68's admission Record (AR) dated 5/21/26, the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses that included depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in daily activities) and malignant neoplasm of stomach (cancer of the stomach).A review of the Minimum Data Set (MDS - standardized assessment and care screening tool), dated 3/27/26, indicated Resident 68 '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 observation, interview and record review, for two of three sampled residents reviewed for respiratory care (Resident 16 and 23), the facility failed to ensure residents received respiratory care in accordance with professional standards of practice when:1. Resident 16's BiPAP (machine is a non-invasive that helps people breathe easier, it delivers pressurized air through a mask, providing a higher pressure when you inhale and a lower pressure when you exhale) equipment was not applied and not maintained as ordered nor did the staff follow required procedures for equipment monitoring and troubleshooting.2. Resident 23's oxygen via nasal cannula was not positioned correctly.These failures had the potential to result in inadequate ventilation support and increased respiratory distress. 1.During a review of Resident 16's admission Record dated 5/19/26, the AR indicated Resident 16 on 5/3/26 with diagnoses that included chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause…

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 2 out of 5 sampled residents (Residents 5 and 95) were free from unnecessary medications. Residents 5 had no hold parameters for an antihypertensive medication (medication to lower blood pressure); and Resident 95 had no monitoring for thyroid stimulating hormone (TSH) while receiving levothyroxine (medication to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone). The failure resulted in inadequate monitoring and had the potential for complications related to these medications such as severely low blood pressure or too low/too high TSH without dose adjustment, for the respective residents. 1. A review of Resident 5's clinical record indicated she was admitted to the facility with diagnoses including atrial fibrillation (is an irregular and often very rapid heart rhythm) and hypertension (high blood pressure [BP]). A review of Resident 5's physician's orders indicated an order for metoprolol (an antihypertensive medication) 25 milligrams (unit of measurement), give 1…

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, record review, and facility policy review, the facility failed to ensure the accuracy of a Level I preadmission screening resident review (PASARR) screening for 1 (Resident #74) of 1 sampled resident reviewed for PASARR screening. Findings included: An admission Record indicated the facility admitted Resident #74 on 08/20/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified disorder of psychological development, unspecified psychosis, and depression. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/23/2024, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include depression, psychotic disorder, and unspecified disorder of psychological development. Per the MDS, the resident received an antipsychotic medication during this assessment period. Resident #74's care plan included a focus area initiated 08/20/2024, revealed…

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 services which met professional standards for one resident (Resident 1) of three sampled residents when nursing staff did not document physician's orders were carried out. This failure contributed to formation and worsening of Resident 1's sacrococcyx (the backside area between a person ' s hips and down to the tailbone) wound. Findings: A review of Resident 1's admission record indicated an initial admission date of 2/15/23 with diagnoses which included mitral valve insufficiency (a condition in which the valve between two heard chambers does not close tightly, which allows blood to flow backward in the heart) and traumatic hemorrhage of the cerebrum (trauma to the head which results in blood intermixing with brain tissue). A review of Resident 1's Braden Scale (an assessment tool used for predicting pressure injury risk) assessment dated [DATE] at 6:22 p.m. indicated a score of 9 which indicated Resident 1 was at very high risk for developing…

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 had a score of 11.43% medication error rate when four medication errors of 35 opportunities were observed during medication pass observation as follows: 1. Eliquis tablet 5 mg (milligram) also known as Apixaban- used to prevent serious blood clots due to irregular heartbeat) was not administered as prescribed by the physician. 2. Metformin HCL (hydrochloride) 500 mg (oral diabetes medicine that helps control blood sugar levels ) was given on an empty stomach. 3. Reglan 10 mg (metoclopramide-use to treat nausea,vomiting) was not administered as prescribed by the physician. 4. Peridex solution (Chlorhexidine gluconate, used as an oral rinse to treat the symptoms of gingivitis-gum disease) 5 ml.(milliliters) was not administered as prescribed by the physician. These failures had the potential of ineffective medication treatment for Residents 45, 318 and 118. Findings: 1. Review of the admission Record indicated Resident 45 was admitted to the facility with multiple diagnoses that included Long standing persistent Atrial…

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

Based on observation, interview, and record review, the facility failed to ensure the nutritive value, flavor, and appearance of the food prior to serving. This failure had the potential to decrease the nutrition status of the residents in promoting recovery from illness or injury. Findings: Observations made in the kitchen on 10/18/21 at 11:50 a.m., showed the bread dressing and pork loin lacked color. The pork loin appeared dry and brussel sprouts looked mushy. During an interview with Resident 61 on 10/18/21 at 1 p.m., Resident 61 stated he could not eat most of his lunch because the chicken was tough and dry and the brussel sprouts were mushy. Resident 61 stated they would not serve food like this at their home, so why would they serve this to us? Surveyor informed Resident 61 it was not chicken but pork loin. Resident 61 stated he could not tell from the taste. During an observation of Resident 61's tray after eating on 10/18/21 at 1 p.m., indicated Resident 61 did not eat the pork loin or the brussel sprouts. During an interview with Resident 170 on 10/19/21 at 10:11 a.m.,…

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, store, and serve food under sanitary conditions when they were using unpasteurized eggs and proper hand washing was not done. These failures had the potential to expose residents who received nutritional services from the kitchen to food borne illness. Findings: 1. During an observation of the kitchen on 10/18/21 at 11:18 a.m.,the eggs stored in refrigerator #3 were not pasteurized. During an interview with the [NAME] on 10/18/21 at 11:50 a.m., [NAME] stated if a resident asked for eggs over easy she would cook them. [NAME] stated she does get that request. During an interview with Dietary Manager (DM) and Dietary Manager Assistant (DMA) on 10/18/21 at 11:20 a.m., stated they were not aware the eggs were not pasteurized. 2. During an observation in the kitchen on 10/18/21 at 12:10 p.m., [NAME] was plating lunches while wearing gloves. [NAME] touched dinner rolls with gloved hand after touching other items. During an interview with [NAME] on 10/18/21 at 1 p.m., [NAME] stated she should have removed…

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 follow infection control practices when; 1. The staff did not wash hands between residents during medication pass for Resident 54 and Resident 7. 2. The staff did not change gloves between residents when obtaining blood pressures (BP) or sanitize the BP cuff for Residents 63 and 22. 3. In the medication room specimen refrigerator, there was a urine specimen dated 10/15/2021 and unlabeled [NAME] - [NAME] (JP- drain is a closed- suction medical device for collecting body fluids from surgical sites) with 30 ml (milliliter) of brown color liquid. These failures increased the potential for cross contamination. Findings: 1. During the medication pass observation on 10/18/2021 at 4:10 p.m., with Licensed Vocational Nurse (LVN ) 1, LVN 1 gave medications to Resident 54 and Resident 7 without performing hand hygiene between resident medication administration. 2. Further medication observation on 10/18/2021 at 4:26 p.m., LVN 1 was obtaining the BP…

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 complete the Comprehensive Minimum Data Set (MDS, an assessment tool used to direct care) within 14-calendar days of admission for two of five sampled residents (Resident 1 and 56). This failure had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for each resident related to the care areas identified on their Comprehensive MDS. Findings: 1. Review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's admission Comprehensive MDS assessment indicated it was due on 4/26/21 and completed on 5/6/21 (10 days late). 2. Review of Resident 56's Face Sheet indicated Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's admission Comprehensive MDS assessment indicated it was due on 5/31/21 and completed on 6/13/21 (13 days late). During an interview with the Regional MDS Coordinator (RMC), on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for three of five (Resident 56, 57, and 58) sampled residents, the facility failed to complete Quarterly Minimum Data Set (MDS, an assessment tool used to direct care) Assessments in the regulatory specified manner. This failure had the potential for Residents 56, 57, and 58 to not receive care and services based on their current health status. Findings: 1. Review of Resident 56's the Face Sheet indicated Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's Quarterly MDS assessment indicated it was due on 8/31/21 and completed on 10/14/21 (44 days late). 2. Review of Resident 57's the Face Sheet indicated Resident 57 was admitted to the facility on [DATE]. Review of Resident 57's Quarterly MDS assessment indicated it was due on 9/9/21 and completed on 10/14/21/ (35 days late). 3. Review of Resident 58's Face Sheet indicated Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's MDS Quarterly MDS Assessment indicated it was due on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one of two sampled residents (Resident 11) was accurately assessed using the Minimum Data Set (MDS - an assessment tool), when Resident 11's MDS was inaccurately assessed as not being a hospice patient. This deficient practice had the potential for Resident 11 to not receive hospice care due to incorrect data entered and receive planned care not consistent with the resident's condition. Findings: During a review of Resident 11's MDS, dated [DATE], which indicated Resident 11 had a BIMS (Brief Interview for Mental Status) score of 02, indicating Resident 11 is severely, cognitively impaired. In addition, it reflected Resident 11 was not receiving hospice care. The medical diagnoses for Resident 11 included heart failure, kidney failure, and Alzheimer's Disease. During a review of Resident 11's physician orders dated 5/3/21 indicated Resident 11 was placed on pallative (relieving pain and optimizing quality of life) care. During an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care that met the professional standards of care for one resident out of 20 sampled (Resident 170) when she was cleaned after being incontinent of feces with Chlorox bleach wipes. This deficient practice had the potential to cause pain and chemical burns to Resident 170. Findings: During a review of Resident 170's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/11/21, indicated she was admitted to the facility on [DATE]. Resident 170 had a BIMS (Brief Interview for Mental Status) score of 13/15, indicating Resident 170 is cognitively intact. The medical diagnoses for Resident 170 included cancer, hip fracture, and pelvic fracture. During an interview with Resident 170 on 10/19/21 at 10:38 a.m., Resident 170 stated the staff from therapy cleaned her after she had a bowel movement and used Chlorox wipes on her bottom. Resident 170 stated she did not know their names and has not seen them since and she thought it was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care for two (Resident 55 and 65) of four residents that required oxygen therapy when Resident 55 and 65 were given oxygen without doctor's orders. These deficient practices had the potential to result in Resident's 55 and 65's inadequate monitoring of Resident 55 and 65's safe use of oxygen and response to oxygen therapy. Findings: A review of the document titled, admission Record, dated 10/21/21 indicated Resident 55 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure (occurs when fluid builds up in the air sacs in your lungs. When that happens, your lungs can't release oxygen into your blood). A review of Resident 55's Minimum Data Set (MDS- an assessment tool) dated 8/11/21 indicated Resident 55 required the use of oxygen. During an observation on 10/19/21 at 11:20 a.m. Resident 55 was using oxygen at 3 liters per minute through a nasal canula (tube with prongs inserted into the nostrils) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide care for three (Resident 44, 45 and 118) of three residents that required dialysis (artificial kidney machine that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood). Staff did not do a complete assessment before Resident 45 and Resident 118's dialysis treatment or complete the dialysis communication record for Resident 45 and 118 before they went to their dialysis treatments. This deficient practice resulted in an inaccurate assessment of Resident 45 and 118's dialysis access site and functionality and failure to communicate potential changes in the resident's physical condition prior to receiving dialysis care. Findings: A review of the document titled, admission Record, dated 10/20/21 indicated Resident 44 was admitted to the facility and had a diagnosis of End Stage Renal (kidney) Disease or ESRD, a longstanding disease of the kidneys leading to renal failure. A review of Resident 44'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.

Based on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) was promptly acted upon for two (Residents 63 and 66) of 20 sampled residents. This failure had the potential for a delay in treatment and risk for serious side effects for Residents 63 and 66. Findings: Review of the admission Record indicated Resident 63 was admitted to the facility with multiple diagnoses that included seizures (a disorder in which nerve cell activity in the brain is disturbed, casing seizures). Review of the facility's Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 8/1/2021 and 9/1/2021, indicated Resident 63 was currently on Carbidopa-Levodopa tablet 10-100 mg (milligram) for seizures. The recommendation indicated please clarify diagnosis for Carbidopa/Levodopa use- this is not used for seizures but Parkinson's Disease. Review of the admission Record indicated Resident 66 was admitted to the facility with multiple diagnoses that included major depressive disorder and dementia (memory disorder) in other disease classified…

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 one (Resident 66) of 20 sampled residents was free from unnecessary psychotropic (drugs that affect the brain activities associated with mental processes behavior) medications when Resident 66 received: 1. Zyprexa ( used to treat certain mental/mood conditions (such us schizophrenia, bipolar disorder) without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risk can be managed by a lower dose or if the dose medication can be discontinued) attempt or resident -specific clinical rationale for continuing the medication since 7/30/2020. 2. Ativan (used to treat anxiety) without a GDR attempt or resident -specific clinical rationale for continuing the medication since 6/25/2020. 3 Paxil (used to treat depression) without a GDR attempt or resident -specific clinical rationale for continuing the medication since 6/8/2020. Review of the admission Record indicated Resident 66 was admitted to the facility with multiple diagnoses that included major depressive 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.

Based on observation, interview, and record review, the facility failed to ensure one (Resident 45) of 20 sampled residents was free of significant medication errors when Eliquis tablet 5 mg (Apixaban- used to prevent serious blood clots due to an irregular heartbeat) was not administered as prescribed by the physician. This failure had the potential for an increased risk of stroke (not enough blood flow and oxygen to the brain due to a clot) when the medication was not provided. Findings: Review of the admission Record indicated Resident 45 was admitted to the facility with multiple diagnoses that included Long standing persistent Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). During the morning medication pass observation and concurrent interview on 10/19/2021 at 9:15 a.m.,with Licensed Vocational Nurse (LVN 2), LVN 2 gave all 9 medications by mouth, except the Eliquis. LVN 2 stated, Resident 45 will not receive her morning dose of Eliquis because it is not available. Review of Physician order dated 9/11/2021 indicated Eliquis…

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 safe medication storage when: 1. In the Medication Room, there were multiple unlabeled, discontinued intravenous (administered into the vein) solution in a medium size plastic bin. 2. Station 3-Medication Cart 3 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart. 3. Station 2-Medication Cart 2 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart. Discontinued medication was still stored in Medication Cart 2 and had multiple opened eyedrops, an unlabeled bottle of nitroglycerine (used for heart/chest pain), and bisacodyl suppositories (laxative) were stored together in a small plastic bin. These failures had the potential for medication tampering, receiving expired medications that could lose their efficacy or the wrong medication. Findings: 1. During a concurrent observation and interview on 10/18/2021 at 5:40 p.m., with the Assistant Director of Nursing (ADON), the medication room had a medium size bin with 10…

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 accuracy of the electronic medical record for one of 20 sampled residents (Resident 2), when Resident 2's medical record had information scanned into it belonging to Resident 171. This deficient practice did not ensure the medical record contained records specifically for Resident 2. For Resident 171, the resident's confidential record was not protected and the Preadmission Screening and Resident Review (PASRR), a screening tool to ensure individuals with mental illness are not inappropriately placed and receive specialized services if indicated) was not readily available to the healthcare team. Findings: During a review of Resident 2's Minimum Data Set (MDS - an assessment tool used to guide care) dated 10/14/21 indicated Resident 2 had a readmission date of 10/6/21. The Brief Interview for Mental Status (BIMS) reflected Resident 2 scored 11/15 which meant moderately, cognitively impaired. Resident 2's diagnoses included end stage kidney…

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.