Villa Scalabrini Special Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when two of two sampled resident (Resident 25 and Resident 53) reviewed under the nutrition task were not assessed and evaluated by a Registered Dietitian (RD- a health professional who has special training in diet and nutrition) after having weight loss. This deficient practice had a potential to result in ineffective nutrition intervention and goals and an increased weight loss for Resident 25 and Resident 53. Findings: a. During a review of Resident 25's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 9/3/2020, and readmitted on [DATE], with diagnoses including absolute glaucoma (a condition marked by complete vision loss and uncontrolled eye pressure), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated…

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

Based on observation, interview, and record review, the facility failed to ensure proper food storage practices by failing to ensure food stored in the facility's dry storage and refrigerator were labeled with an expiration date and opened dated. This deficient practice had the potential to place three of 53 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent kitchen observation and interview on 2/15/2025 at 7:30 a.m., with Dietary Supervisor 1 (DS 1) in the facility's kitchen, observed in the dry storage room, one jar of olives without an expiration date and a five (5) pound (lb. - unit of measurement) bag of buttermilk mix without an open date. Observed in the refrigerator, one (1) gallon of regular milk without an open date. DS 1 stated all food items are to be dated upon receipt with month, day and year. DS 1 stated that the jar of olives should have an expiration date, and the milk and buttermilk mix should have an open date to assure…

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 4 (LVN 4) washed their hands before administering eye drops to one of five sampled residents (Resident 4). 2. Ensure LVN 4 removed their isolation gown prior to leaving a resident's room for one of five sampled residents (Resident 4) who was on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). 3. Ensure a resident's urinal (a container used to collect urine) was labeled with the resident's name for one of two sample residents (Residents 48). These deficient practices had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident`s dignity and respect in full recognition of their individuality when Certified Nursing Assistant 1 (CNA 1) was standing over a resident while assisting the resident during a meal for one of three sampled residents (Resident 25). This deficient practice had the potential to negatively affect the resident`s psychosocial wellbeing and loss of dignity. Findings: During a review of Resident 25's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 9/3/2020, and readmitted on [DATE], with diagnoses including absolute glaucoma (a condition marked by complete vision loss and uncontrolled eye pressure), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2024, the MDS indicated that the resident`s cognitive skills…

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 that the call light (an alerting device for nurses to assist a patient when in need) was within a resident`s reach while in bed for one of one sampled resident (Resident 18) reviewed under the environment task. This deficient practice had the potential to result in Resident 18 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being Findings: During a review of Resident 18's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 10/9/2020, with diagnoses including vascular dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear). During a review of Resident 18's Minimum Data Set (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 observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of one sampled residents (Resident 48), when Licensed Vocational Nurse 1 (LVN 1) left the resident's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated the residents' right to privacy and confidentiality of medical records. Findings: During a review of Resident 48's admission Record, the admission Record indicated that the facility initially admitted Resident 48 on 9/11/2023 with diagnoses including body myositis( IMB- a muscle disease where muscles gradually weaken over time due to the build-up of abnormal protein clumps inside the muscle fiber), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and essential hypertension (a condition in which blood pressure is higher than [NAME]). During a review of Resident 48's Minimum Data Set (MDS - a federally…

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

Based on observation, interview, and record review, the facility failed to obtain a physician order for a resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) setting for one of three sampled residents (Resident 1) reviewed under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential to place Resident 1 at risk for discomfort and development of pressure ulcers/injuries. Findings: During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/13/2021 and readmitted the resident on 9/20/2024 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), epilepsy (a broad term used for a brain disorder that causes seizures [may cause loss of consciousness, falls, or massive muscle spasms]), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable…

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 one of one sampled resident (Resident 45) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to Provide Restorative Nursing exercises as ordered by the physician. This deficient practice had the potential to place the resident in further decline of her range of motion and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 45's admission Record, the admission Record indicated that the facility admitted the resident on 12/25/2024, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and repeated falls. During a review of Resident 45's Minimum Data Set (MDS-a resident assessment tool) dated 12/31/2024, the MDS indicated that 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 observation, interview and record review, the facility failed to ensure the resident environment was free of accident hazards for two of eight residents (Resident 20 and 49) reviewed under the Accidents care area by failing to: 1. Ensure the television in the Resident 20's room is strapped or bolted to prevent it from falling. 2. Ensure licensed nurses did not leave Resident 20's medications at bedside and unattended. Resident 49 was not capable of self-administration of medications. These deficient practices placed the residents at risk for injury and harm. Findings: 1. During review of Resident 20's admission Record, the admission Record indicated the facility admitted the resident on 01/23/2023, with diagnoses including gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining) and Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). During a review of Resident 20's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 09 /30/2024, 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 one of one sampled resident (Resident 13) with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to: 1. Update/revise the care plan (a document outlining a detailed approach to care customized to an individual resident's need) for Resident 13`s indwelling catheter after 6/3/2024. 2. Implement the care plan intervention of monitoring for sign and symptoms of Urinary Tract Infection (UTI-an infection in the bladder/urinary tract) such as pain, burning, blood-tinged urine (red or pink urine), and foul smelling (bad-smelling) urine. These deficient practices had the potential to result in Resident 13 receiving inadequate care and supervision at the facility. Findings: During a review of Resident 13's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 5/31/2024, with diagnoses including unspecified dementia…

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 maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 25) reviewed under the nutrition task, by failing to assess and monitor the resident after having weight loss. This deficient practice had the potential to place Resident 25 at risk for further weight loss. Findings: During a review of Resident 25's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 9/3/2020, and readmitted on [DATE], with diagnoses including absolute glaucoma (a condition marked by complete vision loss and uncontrolled eye pressure), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making 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.

Based on observation, interview and record review the facility failed to ensure licensed nurses check for gastrostomy tube (G-tube, a tube inserted through the abdomen to deliver nutrition and medications directly to the stomach) placement (verifying that a G-tube, is positioned correctly in the stomach and not in another location by aspirating stomach contents through the tube using a syringe) before administration of medications as indicated in the resident's care plan for one of two sampled residents (Resident 4) reviewed under the Tube Feeding care area. This deficient practice had the potential to increase Resident 4's risk of aspiration (the accidental inhalation of foreign material, such as food, liquid into lungs). Findings: During a review of Resident 4's admission Record, the Administration Record indicated that the facility initially admitted Resident 4 on 11/22/2021 and readmitted the resident on 07/02/2023 with diagnoses including gastrostomy tube, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, 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 2. A review of Resident 2's admission Record indicated the facility originally admitted the resident on 2/28/2011 and readmitted on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and chronic kidney disease (a gradual loss of kidney function). A review of Resident 2's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired. The MDS further indicated that Resident 2 was totally dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing and lower body dressing. A review of Resident 2's physician's orders dated 12/16/2022, included an order to administer oxygen at two (2) liters per minute (LPM- unit of measurement) via nasal cannula as needed for shortness of breath or if oxygen saturation (the amount of oxygen that's circulating in the blood) is below 93% (normal reference range 92-100%). During 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.

Based on observation, interview, and record review, the facility failed to ensure call lights (device used by residents that when pressed informs facility staff that assistance is being requested) were within resident's reach while in bed for one of three sampled residents (Resident 27). This deficient practice had the potential to delay the provision of services and resident's needs not being met. Findings: A review of Resident 27's admission Record indicated the facility readmitted the resident on 1/15/2024 with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and unspecified glaucoma (a group of eye conditions that can cause blindness). A review of Resident 27's History and Physical (H&P - a formal assessment of a patient and their problem) dated 2/28/2024 indicated Resident 27 could make needs known but could not make medical decisions. A review of Resident 27's Minimum Data Set (MDS- a standardized assessment and screening tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) did not leave residents' electronic medical records (a digital version of a patient's medical history) open on the medication cart (a device used to store, transport, and organize medications and medical equipment) while the cart was left unattended in the hallway for two of two sampled residents (Resident 1 and 54) investigated for privacy and confidentiality. This deficient practice violated the resident's right to privacy. Findings: a. A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/13/2021 and readmitted the resident on 4/24/2023 with diagnoses including dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and quadriplegia (a symptom of paralysis [complete or partial loss of function] that affects all a person's limbs and body from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LAL - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per manufacturer's guidelines for one of one sampled resident (Resident 1) investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/13/2021 and readmitted on [DATE] with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]), quadriplegia (a symptom of paralysis [complete or partial loss of function]…

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

Based on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen as ordered by the physician for one of three sampled residents (Resident 46). This deficient practice had the potential to result in Resident 46 not receiving the needed oxygen that Resident 46 required. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 8/3/2021 with diagnosis that included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 46's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/18/2024, indicated Resident 46's speech was clear, sometimes made self-understood, and sometimes had the ability to understand others. The MDS indicted Resident 46 had moderately impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 46 required substantial/maximal assistance with eating and…

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

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered a resident's metoprolol (medication that treats high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) with food, as prescribed by the physician for one of five sampled resident (Resident 54). This deficient practice had the potential to place the resident at increased risk of adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated the resident had moderately impaired cognition (a term for the mental processes that take place in the brain) and required moderate…

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: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave medications unattended on top of the medication cart (a device used to store, transport, and organize medications and medical equipment) in the hallway when she walked away from it for one of five sampled residents (Resident 54) observed during the medication administration task. This deficient practice placed residents or unauthorized personnel at risk of accessing the medications. 2. Ensure an unopened insulin (hormone that lowers the level of glucose [sugar] in the blood) pen was refrigerated and not placed in the medication cart for one of five sampled residents (Resident 44) investigated under medication storage and labeling. This deficient practice had the potential for the insulin to lose effectiveness and could result in uncontrolled blood glucoses over time. Findings: 1. A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses…

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 implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report for one of four sampled residents (Resident 1) the result of the investigation of an injury of unknown origin (the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious) within five (5) working days of the incident. This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by CDPH. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/11/2021 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychotic disorder (mental disorder that…

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

Based on interview and record review, the facility failed to provide timely radiology service for one of four sampled residents (Resident 1). On 11/4/2023, Resident 1 had pain and swelling on the left upper arm of unknown origin (the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious); the same day the physician ordered X-rays, but they were not taken until 4/6/2023. This deficient practice resulted in a two-day delay of care and services to treat Resident 1 fracture of the left upper arm. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/11/2021 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychotic disorder (mental disorders that cause abnormal thinking and perceptions), and repeated falls. A review of Resident 1 ' s History and Physical exam, dated 10/27/2023, indicated Resident 1 did not have 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.