Bay Vista Healthcare & Wellness Centre, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one of two residents' (Resident 2) was provided with personal hygiene care. This deficient practice resulted in Resident 2's facial hair being too long to shave with a razor, requiring the use of an electrical razor and had the potential to affect Resident 2's dignity. Findings: During an observation on 6/23/2025 at 10:27 a.m., in the hallway outside of Resident 2's room, Resident 2 was observed with long unkempt facial hair. Resident 2 was observed asking the staff to shave him. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and depression (a mental health condition that causes persistent sadness and loss of interest in activities that were once enjoyable). During a review of Resident 2's Minimum Data Set (MDS- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of two sampled residents (Resident 11 and Resident 60) were provided with a bowel and bladder retraining and/or toileting program (scheduled toileting, prompted voiding or bladder training [help to regain at least some control over patient's bladder]), to regain normal bowel and bladder function as much as possible and received appropriate treatment and services to restore continence. This failure had a potential risk for Resident 11 and Resident 60 to lose their ability to regain control of bowel and bladder function, which could result in loss of dignity. Findings: 1. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including urinary tract infection, (UTI- an infection in the bladder/urinary tract) acute cystitis (a sudden inflammation of the urinary bladder caused by a bacterial infection),…

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 one of six sampled residents (Resident 48) received respiratory care (specialized healthcare field that focuses on the treatment , management and prevention of respiratory disorders) consistent with professional standards of care by failing to: 1.Ensure Resident 48 's nasal cannula (medical device used to deliver supplemental oxygen to a person's nose) was not left on the floor and oxygen concentrator ( medical device that provides a concentrated source of oxygen) were turned off when not in use. These failures had the potential to put Resident 48 for respiratory infection (an infection that affects respiratory tract which includes the nose, throat, and lungs caused by viruses or bacteria). Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dependence on supplemental 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 provide necessary behavioral care and treatment on one of three sample residents ( Resident 167) by failing to: 1.Assess and monitor Resident 167's behavior after verbalization of wanting to die. 2.Follow up physician's notification about Resident's 167 suicidal ideation (thoughts of self-harm or ending one's life). 3.Provide psychiatric (study and treatment of mental, emotional, and behavioral disorders ) evaluation after Resident 167's verbalization of wanting to die. These failures had the potential to put Resident 167 at risk of committing suicide due to delays in care and services. Findings: During a review of Resident167's admission Record, the admission Record indicated Resident 167 was admitted to the facility on [DATE] with diagnoses including hemiplegia partial ( paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting left dominant side, diabetes mellitus…

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 a medication error rate of less than 5% (percent) during medication pass for one of the four sampled residents (Residents 46 ) The facility failed to: a. Administer Resident 46's Onglyza (medication for DM), Sitagliptin (medication for DM) and Risperdal (antipsychotic medication [used to treat schizophrenia and bi-polar]) within 60 minutes of its scheduled time as per facility's policy and procedure (P&P) titled, Medication Administration dated 1/1/2012. These deficient practices of medication administration error rate of 9.09% exceeded the five (5) percent threshold. Findings: During a review of Resident 46 admission Record, dated 6/25/25, the admission Record indicated Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid schizophrenia (a mental illness that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 46) was free from significant medication errors by failing to administer Onglyza for diabetes mellitus 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Sitagliptin for DM 2 and Risperdal (antipsychotic medication) used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) as prescribed by the physician. These failures had the potential to place Resident 46 at risk for hyperglycemia (high blood sugar) and angry outbursts. Findings: During a review of Resident 46 admission Record, dated 6/25/25, the admission Record indicated Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid schizophrenia (a mental illness that is characterized by disturbances in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure transmission-based precautions (set of infection control measures designed to prevent the spread of infectious diseases in healthcare settings) were implemented for one of one sampled resident (Resident 22) who had an order to rule out Clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) due to frequent diarrhea. This failure had the potential to expose other residents, staff and visitors to the spread of infection. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) paranoid schizophrenia(a mental illness that is characterized by disturbances in thought), major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of fear, dread, and uneasiness). During…

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, who had anxiety (an emotional state that involves feelings of fear, dread and uneasiness), and had Ativan (a medication used to treat anxiety) 1 milligram ([mg] a unit of measurement) to control their anxiety, was provided antianxiety medication, for one of five sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Ativan 1 mg for Resident 1 ' s anxiety before the medication ' s quantity was depleted. 2. Ensure Resident 1 received Ativan for anxiety, as ordered by Resident 1 ' s physician. 3. Ensure licensed nurses contacted Resident 1 ' s MD 1 to obtain authorization to access the facility ' s emergency kit ([E-Kit] a kit which contains a small quantity of medications which can be dispensed when pharmacy services are not available) containing Ativan 1 mg to administer to Resident 1. 4. Ensure the licensed nurses followed the facility ' s policy and procedure (P&P) titled, Medication…

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, who lacked the capacity to make decisions, was supervised, and monitored to prevent one of three sampled residents (Resident 1) from eloping (leaving a secured institution without notice or permission) from the facility. Resident 1 was last seen in the facility on 12/12/2024 at approximately 10:30 p.m in his room. Resident 1 was noted missing on 12/12/2024 at approximately 11:30 p.m. As of 12/20/2024, Resident 1 has not been located. This deficient practice resulted in Resident 1 ' s eloping from the facility on 12/12/2024 and his whereabouts being unknown. This deficient practice had the potential for Resident 1 to be exposed to excessive drops in temperature, motor vehicle accidents, hunger, dehydration, and death. Findings During a review of Resident 1 ' s General Acute Care Hospital (GACH) records dated 8/19/2024, the GACH records indicated Resident 1 was admitted to the GACH on 8/9/2024 for aggressive behavior and was put on 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 protect the resident rights to be free from physical abuse for two of six sampled residents (Resident 2 and Resident 4). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 1) separated Resident 1 and Resident 2 immediately when the two residents were arguing over a wheelchair which resulted to Resident 1 throwing a coffee cup to Resident 2's right side of the head. Resident 1 had a recent history of resident-to-resident altercation last June 2024 and Resident 2 had a known aggressive behavior against staff and residents. 2. Protect and prevent Resident 3 from hitting Resident 4 on the face. These failures resulted in Resident 2 sustained a skin abrasion (superficial skin wound) on the right side of the head and Resident 4 getting hit on the face and fell on the floor. Findings: 1.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 5 documented medication as administered in the Medication Administration Record (MAR) immediately after administering Resident 20's Insulin Lispro (a short acting medication used to treat elevated blood sugar level). 2. Ensure LVN 5 verified Resident 20's identity with the MAR prior to medication administration. These deficient practices increased the risk of medication error, including Resident 20 not receiving the correct medication as ordered. 3. Ensure LVN 5 and LVN 2 performed a change of shift inventory of controlled medication (a term used for medications with high level of abuse and dependence) and documented on the count on the facility's-controlled drug count record (a document indicating perpetual inventory and administration of controlled substances) at the beginning and end of each shift per the facility's policy and procedure (P&P) titled, Controlled Medication Storage. This…

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 and sanitary food storage and food preparation practices in the kitchen when: 1. Dusty fan was located near the dishwasher and a dusty radio was located near the kitchen prep table (workstation for food preparation). 2. Facility freezer and refrigerator were not in safe operating condition. 3. A green substance was observed on the spout of the ice dispenser These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (illnesses contracted from eating contaminated food or beverages) of residents who received food from the facility. Findings: 1. During an observation on 6/28/2024 at 3:12 p.m., of the facility's kitchen, a dietary staff was unloading the newly sanitized dishes from the dishwasher and a dusty fan was situated over the dishwasher equipment blowing air to the newly sanitized dishes. Observed a dusty radio was placed close to the kitchen prep table. 2.…

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 infection control practices was implemented. The facility failed to: 1. Ensure personal protective equipment (PPE- equipment used to prevent or minimize exposure to hazards) was easily accessible for direct patient care staff on residents with Enhanced Barrier Precaution (EBP- use of a gown and gloves for residents with wounds, and indwelling devices). These deficient practices had the potential for the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility. 2. Ensure the facility's Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) indicated testing protocols (deliberate action to see if something works) for control measures (actions taken to reduce the potential of exposure to the hazard) and documented results of…

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

Based on observation, interview and record review, the facility failed to ensure three freezers and one refrigerator in the facility's kitchen and food pantry were maintain in safe operating condition. This failure had the resident food items stored in an unsafe condition that could potentially place the residents at risk for food-borne illnesses (illness cause by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During an observation on 6/28/2024 at 3:24 p.m., at the facility's food pantry with the Dietary Supervisor (DS), the following were observed: a. Freezer #1 that stored several bags of frozen tortilla have no thermometer to monitor the freezer's temperature. There was an opened bag of tortilla with no opened date tag and another tortilla bag unopened with ice crystals inside the bag. b. Freezer #2 that stored packed bags of vegetables had a temperature of 2 (two) degrees Fahrenheit (°F a temperature scale) and there was an ice build up observed on the upper portion of the freezer. c. Freezer #3 that stored sliced carrots and french fries had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents receiving hemodialysis ([HD], a medical procedure to remove fluid and waste products from the body) provided necessary care and services for two of two sampled residents (Resident 47 and 26). The facility failed to: a. Ensure Resident 47's blood pressure check was not measured using the left arm with the arteriovenous shunt ([AV] a connection that was made between an artery and a vein for dialysis access). This deficient practice had the potential to interrupt the blood flow to the arm and may cause the AV shunt to stop working. b. Accurately measure Resident 47 and 26's intake and output when a full pitcher of water was left and within reach for Resident 47 and Resident 26. This deficient practice had the potential to cause fluid overload (too much water in the body) for Resident 47 and Resident 26. Findings: a. During a review of Resident 47's admission record, the admission Record indicated Resident 47 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (medication that affects brain activities associated with mental process and behavior) for two of four sampled residents (Resident 64 and Resident 41). This deficient practice had the potential to place Resident 64 and 41 at risk of receiving unnecessary psychotropic medication including Lorazepam (brand name Ativan-medication used to treat anxiety [feeling of fear, dread, and uneasiness], Olanzapine (antipsychotic medication that can treat several mental health conditions) and lithium carbonate (a medication used to treat manic episodes of bipolar disorder) and Resident 41 receiving olanzapine, and Ativan without clinical justification for use. Findings: a.During a review of Resident 64's admission Record, the admission…

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 its medication error rate was less than five percent (%). Two medication errors out of 27 opportunities contributed to an overall medication error rate of 7.14 % affecting one of four residents observed (Resident 33) during medication administration. The medication errors were as follows: 1. Calcitonin Salmon Nasal Solution (a medication used to treat osteoporosis [a disease which causes bones to weaken and break more easily]) 200 units ([U] the amount of a medication administered to a resident in a single dose) one spray was administered in Resident 33's right nostril (outer openings of the nose through which one breathes) instead of left nostrils as ordered by Resident 33 physician. 2. Omission of Calcitonin Salmon Nasal Solution 200 U one spray in Resident 33's left nostril. These deficient practices resulted in failing to administer Calcitonin Salmon Nasal Solution in accordance with the physician's orders and increased the…

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

Based on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality of care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to ensure continued oversight of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey (7/19/2021). This deficient practice resulted in the facility having repeat deficiencies in quality of care, such as pharmaceutical services (procuring, dispensing, distributing, storing, and administering of medications), medication error rate of five percent or more, infection control, and physical environment. Findings: During 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.

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 38) who had a history of post-traumatic stress disorder (PTSD- a mental health condition that triggered by a terrifying event either experiencing it or witnessing it), and depression (a depressed mood or loss of pleasure or interest in activities for long periods of time) was provided individualized plan of care to address potential trauma triggers This deficient practice has the potential not to provide resident centered behavioral health care services needed for Resident 38. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), anxiety disorder (persistent and excessive worry that interferes with daily activities). During 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 interview and record review, the facility failed to ensure one of two sampled residents (Resident 27), who was prescribed with antipsychotic drug (a type of medication prescribed to treat mental health problem) and an anxiolytic drug (anti-anxiety medications, that treat anxiety symptoms and disorders) were monitored for behaviors of bipolar (a mental health condition that causes extreme mood swings) and anxiety episodes every shift. This deficient practice has the potential for Resident 27's behavior of psychosis and anxiety to be unmonitored and has the potential for an inaccurate information necessary for gradual dose reduction ([GDR] tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. and/ or readjustment) of Resident 27 psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications. Findings: During a review of Resident 27's admission Record, the admission…

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 one of one sampled resident (Resident 30) Responsible Party (RP) was notified when the dentist recommended the need for dentures (an artificial placement of one or more teeth). This deficient practice had the potential to cause a delay in dental treatment for Resident 30. Findings: During a review of Resident 30's admission Record, indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (damage or disease which affects the brain), Alzheimer's disease (a progressive disease which destroys memory and other important mental functions), and unspecified dementia (loss of cognitive functioning [thinking, remembering, and reasoning]). During a review of Resident 30's History and Physical (H&P) dated 2/1/2024, indicated Resident 30 did not have the capacity to understand and make medical decisions. During a review of Resident 30's MDS dated [DATE], the MDS indicated Resident 30 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report an allegation of sexual abuse to the California Department of Health (CDPH) Licensing and Certification Program (L&C), State Long Term Care Ombudsman ([LTC] public advocate) and the local Police Department (PD) within the regulated time frame of two hours for one of five sampled residents (Resident 1). This deficient practice resulted in a delay in the investigation of the sexual abuse allegation and had the potential for pertinent data to be lost and/or forgotten. Findings: A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including Parkinsonism (brain condition which causes slowed movements, rigidity [stiffness] and tremors), dementia (impaired ability to remember, think, or make decisions which interferes with doing everyday activities), schizophrenia (a mental health condition which causes hallucinations [when a person hears, sees, smells, tastes or feels…

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 one of one resident's (Resident 1) Preadmission Screening and Resident Review ([PASRR] a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes for long term care), when Resident 1 was newly diagnosed with Schizophrenia (mental disorder affecting thoughts and perceptions) and started on Risperdal (medication used to treat Schizophrenia). This deficient practice has the potential to result in a lack of specialized care and services. Findings: During a review of Resident 1's the admission Record (face sheet-FS), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of sepsis (severe infection), pneumonia (infection that affects one or both lungs), Chronic Obstructive Pulmonary Disease (COPD-group of diseases that cause breathing problems) and muscle weakness. During a review of Resident 1's History and Physical (H/P), dated 2/27/2023, the H/P indicated Resident 1 has 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 interdisciplinary team (IDT) was involved in developing a discharge plan for one of three sample residents (Resident 1), that reflects Resident 1's discharge concerns, needs, goals and treatment preferences. This deficient practice resulted in Resident 1 feeling angry and distrustful of the staff and the failures had the potential to result in an ineffective discharge planning leading to lack of necessary care and services for Resident 1 after discharge. Findings: During a review of Resident 1's the admission Record (face sheet-FS), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of sepsis (severe infection), pneumonia (infection that affects one or both lungs), Chronic Obstructive Pulmonary Disease (COPD-group of diseases that cause breathing problems) and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 9/4/2023, the MDS…

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 immediately transfer one of four sampled residents (Resident 1) to a General Acute Care Hospital (GACH), when Resident 1, whose medical history included a stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts causing damage to the brain), was observed following an unwitnessed fall on 7/21/2023 at 1:30 p.m., with right sided facial drooping (when facial muscles are not aligned), drooling from the right side his mouth, and slurred speech, which were significant signs and symptoms (s/s) of a cerebrovascular accident ([CVA] a stroke) but was not transferred to the GACH until 5:16 p.m. (7/21/2023), 3 hours and 45 minutes after being observed with stroke like s/s. This deficient practice resulted in a delay in Resident 1's evaluation and treatment and the inability for Resident 1 to receive a tissue plasminogen activator ([tPA] a medication used to dissolve intravascular [pertaining to anything…

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's Quality Assessment and Assurance Committee /Quality Assurance Performance Improvement committee (entity responsible for identifying and responding to quality deficiencies in the nursing home) failed to identify internal systemic issues related to the following: 1. Diabetic management (system of coordinated health care interventions for residents with diabetes[disease that occurs when blood glucose is too high])) for 15 out of 15 residents by: a. Not notifying the physicians for blood glucose (type of sugar in the blood) results of greater than 400 milligrams per deciliter (mg/dL). (normal blood glucose level for diabetic is between 70-130 mg/dl before meals), b. Not monitoring signs and symptoms after residents had blood glucose greater than 400 mg/dL, and c. Not re-checking the blood glucose after administering insulin (medication that lowers the blood glucose ) for results greater than 400 mg/dL. 2. Medication regimen review (process in which the licensed pharmacist reviews all the medications the residents are currently taking…

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 freezer temperature was maintained within safe operating conditions on or below 0 degrees Farenheit (F). This failure had the potential to cause food borne illness due to improper temperatures to prevent bacterial growth. Findings: During an observation of the kitchen on 7/13/21 at 8:25 a.m., the reach-in freezer thermometer was observed to have a temperature of 10 degrees Farenheit (F). At 9:34 a.m. the freezer temperature was observed to be at the same temperature at 10 degrees F. During an interview with the dietary supervisor (DS) the freezer was constantly being opened as the reason for the high temperature. The contents of the freezer included frozen sorbet in cups, frozen assorted cooked meat, frozen hot dogs and frozen tater tots. All items were cold and solid hard to the touch. During an interview on 7/13/21 at 4:40 p.m. the DS stated she will move the frozen items to the spare freezer in the basement. During a concurrent observation, the kitchen staff were obsereved moving items 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 observation, interview, and record review the facility failed to ensure Resident 41 had a bedside commode (a piece of furniture containing a concealed chamber pot) or toilet riser to assist resident with toileting. This deficient practice had the potential not to meet Resident 41's needs in toileting and promote independence and safety. Findings: During a review of Resident 41's admission Record (Face Sheet), the face sheet indicated Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnoses including displaced intertrochanteric fracture of left femur (broken left hip), respiratory failure with hypoxia (absence of enough oxygen), and chronic obstructive pulmonary disease (progressive disease that makes it hard to breath). During a review of Resident 41's Minimum Data Set (MDS), assessment and care-planning tool, dated 6/18/2021, the MDS indicated Resident 41 had no cognitive (ability to learn remember, understand and decisions) impairment for daily decision making. The MDS indicated…

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 follow the plan of care to keep blood sugar levels in control with stable numbers for one of one resident (Resident 45), who was diagnosed with diabetes (abnormal blood sugar levels) by failing to: Follow the physician's orders to notify the physician when Resident 45 blood sugar levels were 400 mg/dL or greater (normal blood sugar level is between 70 130 milligram/deciliter [mg/dL]). This failure resulted in the physician not notified when Resident 45's blood sugar levels reached 400 mg/dL and above per the sliding scale (the dose of insulin (Lispro, medication given to lower blood sugar level), to be given depending on the blood sugar results) for total of 16 times in May 2021, 15 times in June 2021, and 20 times in July 2021 . Findings: During a record review of Resident 45's admission Record, face sheet (document gives resident quick information briefly), indicated the resident was admitted on [DATE]. Resident 45's diagnoses included type 2…

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 implement repositioning care plan interventions for two of three residents (Residents 23 and 36). This deficient practice had the potential for formation of pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to Residents 23 and 36. Findings: a. During a concurrent observation and interview on 7/13/2021, at 9:10 a.m., Resident 23 stated the nursing staff did not reposition her every two hours and she was only reposition a few times per week. Resident 23 stated she was able to pull herself up with the trapeze (a medical trapeze hangs over the bed to function as a grab bar, providing leverage for patients with upper body strength to position themselves without help), but was not able to turn from left to right without help. Resident 23 stated sometimes her buttocks (tail bone) was sore. Resident 23 stated nursing staff does not offer to turn me throughout the day. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. During an interview on 7/14/21 at 10:14 a.m., Resident 13 stated curtains are left open during incontinence care by different staff members. The resident stated, I feel ashamed because everyone can see my body. During a concurrent observation and interview on 7/19/21, at 10:15 a.m., with Licensed Vocational Nurse (LVN 9) inside Resident 13's room, LVN 9 was observed exposing genital area while assessing the resident's indwelling catheter (Foley catheter) with the privacy curtain partially opened. During a consequent interview with LVN 9, she stated she did not provide privacy to the resident by not pulling the curtain fully around the resident's bed. LVN 9 stated the facility policy was to always provide privacy because it is their right, for dignity, and respect. During an interview on 7/19/21 at 11:29 a.m., the Director of Staff Development/ Infection Preventionist (DSD/IP) stated, while providing incontinence care, staff are educated to knock, introduce themselves, and let the resident's know what they are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure medication was available for Resident 44 2. Ensure controlled medications were entered into the disposition logbook for Residents 15, 57, and 38. These deficient practices increased the risk that medications may not be available for Resident 44 when needed and had the risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use), or accidental exposure to controlled substances. Findings: a. A review of Resident 44's Facesheet (admission record) indicated the resident was admitted on [DATE], with a diagnosis not limited to diabetes type 2 (abnormal blood sugar), gastroesophageal reflux disease ([GERD] reflux of the stomach contents into the esophagus), thrombocytopenia (an abnormal drop of blood cells involved in forming blood clots in the blood), and dementia (memory loss). A review of quarterly Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/11/2021,…

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 it was free of medication error rate of less than five percent, as evidenced by the identification of two (2) medication errors out of twenty-seven (27) opportunities for error, to yield a cumulative error rate of 7.41 percent for two of four sampled residents (Residents 35 and 44). 1. Failed to ensure administration of the correct dose of Vitamin C given to Resident 35. 2. Failed to have Pyridoxine (Vitamin B6) available to ensure Resident 44 received the medication per physician order. These deficient practices had resulted in Resident 35 and Resident 44 not receiving their medications as ordered by the physician. Findings: a. A review of Resident 35's Facesheet (admission record) indicated the resident was admitted on [DATE], with diagnoses not limited to hemiplegia (total or partial paralysis of one side of the body), diabetes type 2 (abnormal blood sugar), gastrostomy tube ([gtube]a tube that is placed directly into 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 and record review, facility failed to: 1. Ensure an counter medications (OTC), had a date opened on the bottle for one Resident (213). 2. Ensure emergency kits (ekits)[storage receptacle that contains a drug supply that can be used for residents during emergencies] were replaced within 72 hours of access per facility policy. These deficient practices had the potential for harm for Resident 213 to receive ineffective, and expired medication, stored in the medication carts and the potential for unavailability of medication for the residents during an emergent situation. Findings: a. During a concurrent observation and interview on [DATE], at 9:00 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 213's Vitamin D3 125 mcg 5000 IU 1-tab over the counter medication was observed opened but did not indicate a dated as to when it was opened. LVN 3 stated OTC medications are supposed to be dated with an open date. During an interview on [DATE], at 2:52 p.m., Registered Nursing Supervisor (RN…

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 use the correct portion size for pureed (paste or thick liquid suspension made from finely ground cooked food) chicken during lunch service for four of 4 residents (Resident 18, 31, 39 and 213) This deficient practice had the potential the residents on a pureed diet to receive less than the required amount of protein as indicated on the therapeutic diet menu (spreadsheet indicating all diet types). Findings: During a lunch tray observation on 7/13/21, starting at 12:00 p.m., Dietary [NAME] (Cook 1) was observed using a blue-colored number (#) 12 scooper (1/3 cup) of pureed chicken and gravy (protein) onto Resident 18, 31, 39 and 213's plate. During an interview and concurrent record review of the residents' therapuetic diet menus on 7/13/21 at 12:50 p.m., [NAME] 1 stated that each resident on a puree diet should get four ounces (1/2 cup) of puree chicken. [NAME] 1 stated it was important for the residents to receive the correct amount 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 facility failed to ensure : a. Competency for the laundry staff to maintain and use washing machines temperature in according to manufacturer's instruction. b. Infection control practices were maintained during incontinent care for Resident 23 c. Infection control practices were maintained for storing and cleaning of shower chairs This deficient practice had the potential for microbial contamination of soiled linens that can cause potential spread of infection for the residents, and spread of infections and communicable diseases due to non-adherence of infection control practices. Findings: a. During a concurrent observation and interview on 7/15/2021 at 12:00 p.m., three laundry washers was observed in the laundry room Laundry Aide (LA) with stated she takes laundry from the laundry shoot and sorts them out into three bins. LA stated that the first washer temperature was at 170 degrees but did not know how to where to check the temperatures of the washers. LA…

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 privacy was provdied during assessment an indwelling urinary catheter (a sterile tube inserte into the bladder to drain urine) for one of two residents (Resident 13). This deficient practice resulted in Resident 13 feeling embarassed. Findings: During an interview on [DATE] at 10:14 a.m., Resident 13 stated curtains are left open during incontinence care by different staff members. The resident stated, I feel ashamed because everyone can see my body. During a concurrent observation and interview on [DATE], at 10:15 a.m., with Licensed Vocational Nurse (LVN 9) inside Resident 13's room, LVN 9 was observed exposing genital area while assessing the resident's indwelling catheter (Foley catheter) with the privacy curtain partially opened. During a consequent interview with LVN 9, she stated she did not provide privacy to the resident by not pulling the curtain fully around the resident's bed. LVN 9 stated the facility policy was 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 ensure the quarterly Minimum Data Set (a comprehensive standardized assessment and screening tool [MDS]) was completed within the required time frame for one of four sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 1. Findings: During a review of Resident 1's admission Records (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included sepsis (blood poisoning by bacteria), pneumonia ( an infection of the lungs), encephalopathy (brain disease, damage, or malfunction), type 2 diabetes (a condition that occurs when the body can't use glucose [a type of sugar] normally), and quadriplegia( paralysis caused by illness or injury that results in a partial or total loss of use of all their limbs and torso). During a record review of Resident 1's Minimum Data Set (MDS) a resident assessment and care…

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 change the or oxygen tubing for one of two residents (Resident 32) and to change a nebulizer mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for one of two residents (Resident 51) based on facility's policy and procedure. This deficient practice had the potential for respiratory infections for Resident 32 and 51. Findings: a. A review of the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia ( absence of enough oxygen), chronic pulmonary edema (excess fluid in the lung ), chronic obstructive pulmonary disease (progressive disease that makes it hard to breath), chronic systolic congestive heart failure condition in which the heart cannot pump enough blood). During a review of Resident 32's Minimum Data Set (MDS), assessment and care-planning tool, dated 6/13/2021, the MDS indicated Resident 32 had no…

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 fortified soup was prepared following the recipe for three of 3 residents (Resident 3,18 and 40). This deficient practice had the potential to result in diminished nutritive value of food served to the residents. Findings: a. A record review of Resident 18's face sheet (admission record) indicated Resident 18 was admitted on [DATE] with a diagnosis including but not limited to Alzheimer's disease (type of dementia affecting memory, thinking and behavior), dysphagia (difficulty swallowing), and adult failure to thrive. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/30/2021, indicated Resident 18 had moderately impaired cognitive skills (ability to think, read, learn, remember, reason, and pay attention) for daily decision making and staff supervision was required. A review of the physician orders dated 7/16/2021 indicated Resident 18 had an order for fortified soup with lunch…

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.