Touchpoints At Bloomfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of the clinical record, and facility policy for 2 of 2 sampled residents (Resident #140 and Resident #141) reviewed for Infection Control practices and who were receiving intravenous antibiotics, the facility failed to obtain physician's orders for a central line (catheter residing in a large vein with the tip ending near the heart) intravenous flushing, for external catheter length measurement, and for Resident #140 measurement of arm circumference. The findings include:1. Resident #140's diagnoses included streptococcal (bacteria) infection, osteomyelitis (bone infection) of both feet and ankles, and Type 2 Diabetes.The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #140 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition independence with eating, toileting and personal hygiene and was receiving intravenous medications.The Resident Care Plan dated 11/12/25 identified Resident #140 was currently on IV antibiotics via 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 observations, interviews, and facility policy for the only sampled Resident (#1) reviewed for specialized treatment, the facility failed to ensure physician's orders were obtained for the functioning and care of an Arteriovenous Fistula (AVF) (used for specialized treatment access). The findings include:Resident #1's diagnosis included cerebral infarction, diabetes, and end stage renal disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment, was independent with bed mobility, transfers, and wheelchair mobility, and was receiving specialized treatments. The Resident Care Plan (RCP) meeting notes and RCP dated 8/29/25 indicated Resident #1 had a left upper chest catheter and was receiving specialized treatments through the catheter twice weekly. Additionally, Resident #1 had an AVF placed to the right arm on 2/14/25 which was still healing, not yet used for specialized treatments, 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 observations, interviews, review of the clinical record, and facility policy for 1 of 2 residents reviewed for pressure ulcers (Resident #10) and 2 of 6 residents (Resident #90 and Resident #140) reviewed for infection control, the facility failed to ensure appropriate Personal Protective Equipment (PPE) use during high contact care for residents who required Enhanced Barrier Precautions (EBP), additionally, for Resident #10, the facility failed to perform appropriate hand hygiene and glove changes during wound care. The findings include: Review of the Enhanced Barrier Precaution Policy identified that an orange dot would be placed next to the name outside of the door for residents requiring EBP. 1. Resident #10's diagnoses included a stage 3 pressure ulcer, fracture of the left femur, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 had a Brief Interview of Mental Status (BIMS) score of 7 indicating severely impaired cognition, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, and review of facility documentation and policy for three of four residents, that resided on one of five nursing units reviewed for physical environment, the facility failed to ensure an effective pest control program was maintained to prevent rodents. The findings included:1. Resident #1 was admitted to the facility November 2024 and had diagnoses of Parkinson's Disease, Type 2 diabetes mellitus, and limitation of activities due to disability.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severe cognitive impairment. The MDS further identified Resident #1 was dependent with eating, oral, toileting, and personal hygiene.Review of Resident #1's RCP dated 4/16/25 identified impaired coping and wound management. Interventions directed to encourage the resident to verbalize feelings regarding fear and/or anxiety and monitor ulcer for signs 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 review of the clinical record, facility documentation and interviews for one (1) of five (5) residents (Resident #3), reviewed for wnaderguards, the facility failed to ensure that Resident #3 had a physician's order directing to check placement and functionality of the Wanderguard. The findings include: 1. Resident #3's diagnoses included cerebral infarction (blood flow to the brain is interrupted causing brain tissue to die), dementia without behavioral disturbances and mild cognitive impairment. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of zero (0) indicative of severely impaired cognition and was independent with bed mobility, transfers and ambulation. Additionally, it identified that Resident #3 utilized a wander/elopement alarm. The Resident Care Plan (RCP) dated 1/10/25 identified that Resident #3 is at risk for elopement due to limited insight into his/her illness or abilities with interventions that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for unauthorized leave, the facility failed to ensure that when a resident was identified as missing from the facility by staff, the missing person protocol was initiated which allowed the resident to walk 3.6 miles in 27 degree weather passing multiple major intersections and having to cross main roads to get to his/her destination. The findings include: Resident #1 had diagnoses including schizophrenia and alcohol abuse. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of twelve (12) indicative of moderately impaired cognition and was independent with bed mobility, transfers, toileting and ambulation. Review of the Capacity to Meet Minimal Basic Needs Interview dated 10/10/24 identified that the resident does not have the capacity to meet minimal basic needs in the community 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from abuse. The findings include: a. Resident #2's diagnoses included depression and chronic pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented, had no behaviors, and ambulated with a walker independently. The Resident Care Plan (RCP) dated 9/3/2024 identified Resident #2 used antidepressant medication. Interventions directed to administer medications as ordered, and monitor for side effect. b. Resident #3's diagnoses included Parkinson's, bipolar disorder, borderline personality disorder, paranoid schizophrenia, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately cognitively impaired, ambulated independently, and had no behaviors. The Resident Care Plan (RCP) dated 10/9/2024…

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, review of facility policy and interviews, the facility failed to ensure dietary staff wore proper hair restraints, food served within acceptable temperature parameters and that the kitchen was maintained in a clean and sanitary condition. The findings include: Observation during the initial tour of the kitchen on 2/20/24 at 9:45 AM with the Food Service Director identified the floor was sticky and had multiple areas that contained visible debris. Interview on 2/20/24 at 9:50 AM with the Food Service Director identified that the Dietary Aide was just about to mop the floor, and that it is done twice daily. When a sign off on the task list was requested the food Service directed noted there was no sign off for the task just a list of tasks to be completed. Observation on 2/20/24 at 10:02 AM identified Dietary Aide #1 portioning cake onto plates with long hair several inches past her shoulders with no hair restraint. Interview with the Food Service Director on 2/20/24 at 10:08 AM identified that Dietary Aide #1 should be wearing a hair restraint while portioning…

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 review of facility documentation, review of facility policy, and interview, the facility failed to review the infection prevention control program policies and procedures at least annually, and failed to provide documentation that environmental rounds were conducted on a quarterly basis. The findings include: a. Review of the facility's Infection Control Program Policies and Procedure manual for the past two years on 2/22/24 at 10:52 AM identified that the policies and procedures manual was reviewed on 1/19/23 but was not reviewed in 2022. Interview with the Infection Preventionist Nurse (RN #3) on 2/22/24 at 10:52 AM identified that the policy and procedures manual should be reviewed annually but was not working at the facility during the time it was due to be completed. A policy for review and renewal of the infection control program policies and procedures was requested but was not provided by the facility. Interview with the Administrator on 2/27/24 at 3:30 PM identified she was unable to locate a policy but identified that it was the practice of the facility to review…

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 review of facility documentation, review of facility policy and interviews, the facility failed to ensure that a review of the antibiotic stewardship program including antibiotic usage was presented at the quarterly medical staff meetings. The findings include: A review of the infection control program for the past two years with the Infection Preventionist Nurse (RN #3), Corporate Director of Education (RN #4) and Corporate Director of Education and Infection Preventionist (RN #5) on 2/22/24 at 10:52 AM failed to identify documentation related to monthly review of the antibiotic stewardship program for the period of January 2022 to September 2022, December 2022, and February 2023 to June 2023. The facility also failed to provide quarterly review Medical Staff Meeting Reports documentation related to quarterly review of antibiotic usage for 2022 and 2023. RN # 3 identified that he started working at the facility in November of 2023 and would contact the physician or the facility APRN's directly if he had any issues that needed to be addressed such as laboratory reports,…

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 review of facility documentation, review of facility policy and interviews for five of five sampled nurse aides (NA #4, NA #5, NA #6, NA #7, and NA #8), the facility failed to ensure that the required 12 hours of in-service training including abuse were provided to staff in 2022 and 2023. The findings include: Review of the facility's mandatory yearly in-service training for NA #4, NA #7, and NA #8's identified the facility was unable to provide documentation that a total 12 hours of training that included abuse and dementia was completed for the year 2022. Review of the facility's mandatory yearly in-service training for NA #4, NA #5, NA #6, NA #7, and NA #8's identified the facility was unable to provide documentation that a total 12 hours of training that included abuse and dementia was completed for the year 2023. Interview with Staff Development Nurse (RN #3), Corporate Director of Education (RN #4) and Corporate Director of Education and Infection Preventionist (RN #5) on 2/27/24 at 3:10 PM…

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 review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #112) reviewed for resident-to-resident mistreatment, the facility failed to provide the necessary supervision to prevent a resident-to-resident altercation. The findings include: Resident #112's diagnoses included unspecified dementia, schizophrenia, and post-traumatic stress disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #112 was cognitively intact, required the assist of one for toileting, showering, lower extremity dressing, required maximum assistance for personal hygiene and received psychological therapy. A reportable event report dated 11/12/23 at 9:30 PM identified Resident #112 was hit in the nose by another resident over a disagreement regarding the community television resulting in a skin tear to the bridge of the nose. The report notes that the residents were immediately separated, 911 was called and the resident who…

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 clinical record review, facility documentation review, facility policy review, and interviews for one sample resident (Resident #241) who was newly admitted to the facility from an acute care hospital, the facility failed to ensure that a registered nurse assessed the resident upon admission in accordance with the facility's policy and professional standards of care. The findings include: Resident # 241 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis to the left shoulder, bicipital tendinitis to the left shoulder, and status post arthroplasty to the left shoulder. The late entry nurse's note written by RN #6 (former DNS) dated 8/27/22 at 8:00 PM identified Resident #241 arrived at the facility via stretcher with diagnoses of arthritis to the left shoulder, bicipital tendinitis to left shoulder, and status post arthroplasty to the left shoulder. It noted Resident #241 was alert, oriented and able to verbalize needs. The note further noted that the physician was notified…

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 clinical record review, observation, facility documentation review, facility policy review, and interviews for one of four sampled residents (Resident #46) who had a facility acquired pressure ulcer, the facility failed to ensure the initial assessment of the wound was completed by a registered nurse and failed to provide treatment in a timely manner. The findings include: Resident #46 's diagnoses included end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, anemia, and left foot drop. The Braden scale risk assessment used to predict the risk for pressure ulcer development dated 10/30/23 identified Resident #46 was at mild risk with a score of 16 (a score of 19-23 is indicative of low risk, a score of 15-18 is indicative of mild risk, a score of 13-14 is indicative of moderate risk, a score of 10-12 is indicative of high risk and a score of 9 or below is indicative of severe risk). The admission MDS assessment dated [DATE] identified Resident #46 had intact cognition,…

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 clinical record review, and interviews for one sampled resident (Resident #77) reviewed for enteral nutrition, the facility failed to ensure physician's orders were clearly and completely written as well as transcribed onto the medication administration record (MAR) and failed to notify the physician when medications and enteral nutrition were not administered due to the clogging of the gastrojejunostomy tube (g-tube/j-tube). The findings include: Resident #77's diagnoses included gastrojejunostomy placement, Huntington's disease, and unspecified dementia. The admission MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] identified Resident #77 had intact cognition, and required extensive assistance with bed mobility, transfers, did not ambulate, required a wheelchair, and utilized a feeding tube. The Resident Care Plan dated 2/4/2024 identified Resident #77 had a feeding tube because it is unsafe for them to eat or drink with interventions that included: if there is poor skin…

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 clinical record review, facility documentation review, facility policy review, and interviews for two sampled residents (Resident #107 & #241) reviewed for pain, the facility failed to ensure pain assessments were completed on admission and failed to document the administration of as needed pain medication and the assessment of the effectiveness of the pain medication. The findings include: 1. Resident #107's diagnoses included left leg fracture, anxiety, and suicide attempt. The admission Minimum Data Set assessment dated [DATE] identified Resident #107 had intact cognition, required supervision or touch assistance for showering, lower body dressing, transferring from bed to chair, and had pain. The care plan dated 1/5/24 identified Resident #107 had pain with interventions that included: provide pain medication as ordered, observe its effectiveness, and provide non-pharmacological interventions. A physician's order dated 1/8/24 directed to administer Oxycodone (Opioid) 5mg one tablet by mouth every 6…

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 clinical record review, facility documentation review, facility policy review, and interviews for one sample resident (Resident #34) reviewed for dialysis, the facility failed to ensure fluid intake was monitored for a resident with a fluid restriction. The findings include: Resident #34 's diagnoses included end-stage renal disease, anemia, type 2 diabetes mellitus and dependence on renal dialysis. A physician's order dated 1/8/24 directed a 1500 milliliters (ml) fluid restriction per day. The quarterly MDS assessment dated [DATE] identified Resident #34 had intact cognition, required extensive assistance with mobility, transfers, toileting, hygiene, and received dialysis services. The Resident Care Plan (RCP) dated 1/22/24 identified Resident #34 had end stage renal disease that required hemodialysis. Care plan interventions directed to arrange follow-up with nephrologist as needed, cover the wound, and apply firm pressure if bleeding noted to the access site, monitor weight and vital signs as…

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 observations, clinical record review, facility policy review, and interviews for four residents (Resident #36, 61, 62, 242), the facility failed to ensure expired medications were not in use and removed from the medication cart, failed to date insulin when opened, and failed to ensure medications were stored according to the manufacture's recommendation. The findings include: a. Resident #36's diagnoses included type 2 diabetes mellitus, hyperlipidemia, and anxiety disorder. Resident #36's physician's orders for the month of February 2024 directed to administer Lantus 100units/milliliter (U/ml) inject 30 units subcutaneously (SC) at bedtime for diabetes. The medication administration record (MAR) for the month of February 2024 identified Resident #36 was administered Lantus 30 units subcutaneously at 9pm nightly from February 1, 2024, to February 25, 2024. Observation of the Windsor right medication cart on 2/26/24 at 11:34 AM with Charge Nurse (LPN #5) identified an opened vial of Lantus 100u/ml for Resident #36 that was ¼ full with a label that consisted of an opened date…

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 clinical record review, facility documentation, facility policy and interviews for one sampled resident (Resident #102) reviewed for grievances, the facility failed to follow through promptly on a grievance. The findings include: Resident #102's diagnoses included chronic kidney disease (hemodialysis), diabetes mellitus type 2, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #102 had intact cognition, utilized limited assistance for bed mobility, and transfers, and was non- ambulatory. The Resident Care Plan dated 11/3/2022 identified Resident #102 may have impaired communication related to the primary language being Spanish with interventions that included: introduce yourself, when possible, ask yes or no questions, speak distinctly, rephrase, or use gestures to communicate, allow adequate time to find words, do not rush, and stand where face is visualized. A missing personal property report dated 11/11/22 completed by the Social Work Director identified…

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 clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #207) who required continuous intravenous infusion, the facility failed to ensure agency licensed nursing staff received training on how to operate a Continuous Ambulatory Delivery Device (CADD) pump. The findings include: Resident #207's diagnoses included chronic systolic congestive heart failure. A physician's order dated 1/7/21 directed Milrinone in D5W 20-5 milligrams/100 milliliters % solution infusion, infuse 0.0318 mg per minute into a venous catheter continuously. The admission Minimum Data Set assessment dated [DATE] identified Resident #207 made consistent and reasonable decisions regarding tasks of daily life and received an intravenous (IV) medications while a resident. The Resident Care Plan dated 1/19/21 identified Resident #207 had congestive heart failure and was currently on a Milrinone IV drip via pump to his/her right chest [NAME] catheter. Interventions directed 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 review of the clinical record, facility documentation, and interviews for 1 resident reviewed for dysphagia, (Resident #85), the facility failed to ensure that the patient's bed was properly functioning prior to a room transfer. The findings include: Resident #85 had a diagnosis of Alzheimer's dementia and dysphagia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment and required total care with activities of daily living. Review of a speech therapy note dated 7/6/21 identified that the resident had dysphagia and should be fed in an upright position. A nurse's note dated 7/19/21 identified that the residents family member had requested a room change due to the air conditioner in the resident's current room, the daughter was showed another room and approved of the room change and the resident was transferred. Review of a grievance form dated 7/19/21 identified that the family member had a concern for the positioning of Resident #85 while being fed. 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.