Oaks Of Clearwater, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure documentation was accurate and complete in the Electronic Medical Record (EMR) for one resident (#35) out of 13 residents reviewed.Findings included: Resident #35 was admitted to the facility on [DATE]. Review of Resident #35's medical record revealed medical diagnosis to include muscle wasting and atrophy, difficulty in walking, generalized anxiety disorder, and dementia.Review of the Minimum Data Set (MDS) dated [DATE], section C revealed the resident had a Brief Interview Mental Status of 09, which meant the cognition of Resident #35, was moderately impaired. Section GG of the MDS revealed the resident required supervision or touching assistance. It showed Resident #35 required partial or moderate assistance for toilet transfers. Section H revealed Resident #35 was incontinent frequently.Review of a Certified Nursing Assistant (CNA) Kardex (A documentation platform used by staff with instructions to specific resident care needs) revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to thoroughly investigate a voiced grievance for one resident (#3) out of four sampled residents. Findings included:On 07/24/2025 at 02:35 P. M., a phone interview was conducted with Resident #3's family member. She stated she was unable to speak with the Nursing Home Administrator (NHA), via phone call because she could not be reached. She stated she was able to communicate with the NHA through text messaging. She stated she had concerns about the care her family member was getting and she notified the NHA of her concerns. She stated the NHA was dismissive of her. She stated she never heard from the facility with what happened. Review of Resident #3's medical records revealed she was admitted to the facility on [DATE], with a discharge date of 07/16/2025 to another facility. Diagnoses for Resident #3 included: wedge compression fracture of vertebra, and depression. A review of the progress notes revealed the following: 6/19/2025 12:01 Communication with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, resident and staff interviews, observations, and policy and procedure review, the facility did not ensure an injury of unknown origin was thoroughly investigated in a timely manner for one resident (#1) of three residents reviewed for alleged violations of abuse and mistreatment. Findings included: Review of the record for Resident #1 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disorder and anxiety; anxiety disorder; major depressive disorder; other specified persistent mood disorders; pain, unspecified; polyneuropathy; and unspecified mood affective disorder. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5 out of 15, indicating severe cognitive impairment. The assessment revealed Resident #1 required substantial/maximum assistance for toileting hygiene. 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 maintain confidentiality of Protected Health Information (PHI) related to a bulletin board located in one of one nurses' station for a census of 52 residents related to having Do Not Resuscitate (DNR), mobility, tube feeding, and dialysis status being visible and accessible to visitors, residents, and staff members. The information was displayed at the nurse's station and the East Wing hallway bulletin board. Findings included: An observation on 09/19/23 at 9:00 a.m., behind the nurses' station located between the east and west wing, revealed a cart that contained all of the resident charts that showed the resident's name, room number and status of Do Not Resuscitate (DNR) for twenty-eight residents. (Photographic Evidence Obtained) An additional observation on 09/19/23 at 9:00 a.m. revealed a bulletin board located on the East Wing hallway with a sign titled, 11-7 Get Up List and displayed two columns labeled as Dependent and Independent. This list showed resident room numbers, their first names and last…

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, record review and interview the facility failed to ensure a safe, clean and homelike environment for six resident rooms (#200, #202, #207, #212, #213, and #224) of 22 rooms in the facility. Findings included: 1. An observation on 09/18/23 at 3:34 p.m. of Resident room [ROOM NUMBER] revealed: (Photographic Evidence Obtained) - Multiple ceiling tiles throughout the room were separate or disconnected from the rest of the ceiling. - The air vent located near the door had dust build up in the vent. - Wallpaper was torn and missing around the air vent. - Ceiling tiles had bio growth that discolored areas of the tiles. - A white garbage bag with multiple gnats flying in and around the bag was located on the top of a clothing armoire. During an interview on 09/20/23 at 2:00 p.m. the Director of Nursing (DON) and Assistant Director of Nursing/Unit Manager (ADON/UM) observed the bag of gnats in Resident room [ROOM NUMBER]. ADON/UM looked at the bag of gnats and stated, .I hate bugs. The DON stated…

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, record review and interview the facility failed to ensure food was labeled and dated when stored in the walk-in refrigerator, the walk-in refrigerator log was completed daily and the dishwasher was functioning properly in accordance with professional standards for food service safety in one of one kitchen with the potential to affect 51 of census of 52 residents. Findings included: An observation on 09/18/23 7:00 a.m. revealed food items located in the kitchen's walk-in refrigerator were not labeled and dated. The food items not labeled or dated included: (Photographic Evidence Obtained) - metal container of white thick gravy - metal container of brown thick gravy - A bag of 10 eggs - A bag of six rolls - A bag of cut broccoli - A bag of approximately 12 hot dogs - A wrapped up cucumber - Two heads of lettuce. During an interview on 09/18/23 at 7:05 a.m. Staff D, Dining Room Manager (DRM) confirmed the food items were not labeled or dated. Staff D, DRM stated that all food should be labeled and dated before being stored in the walk-in refrigerator. An…

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, record review and interview the facility failed to ensure one resident (#209) of six residents observed for in-room dining and two residents (#4 and #26) of nine residents observed for communal dining received a dignified dining experience. Findings included: 1. An observation, on 09/18/23 at 4:43 p.m. showed Resident #209 sat in her wheelchair at a bedside table and stated, I am hungry. Resident #209's roommate was observed with a dinner tray eating as Resident #209 watched her roommate eat dinner. Resident #209 stated her tray always came late and on a different cart. Resident #209 stated she had been receiving her tray later, after her roommate was served, since being admitted to the facility three days ago. (Photographic Evidence Obtained) During an interview on 09/18/23 at 4:45 p.m. Staff A, Licensed Practical Nurse (LPN) stated the tray pass was a problem around here. Staff A, LPN stated food should be delivered to roommates together but that did not always happen because the trays…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately assess a discharge on the Minimum Data Set (MDS) for one resident (#56) of three residents reviewed for transfer and discharge. Findings included: A review of Resident #56's admission Record showed Resident #56 was admitted to the facility with diagnoses of Parkinson's Disease, dysphasia, pneumonitis and dysphonia. A review of the Discharge Return Not Anticipated MDS, dated [DATE], showed in Section A 2100 Discharge Status that Resident #56 was discharged to an Acute hospital. Review of a physician order, dated 07/19/23, showed, discharge to apartment in Assisted Living Facility. Review of a Plan of Care Note, dated 6/28/2023, showed, Care plan meeting held with IDT (interdisciplinary team), [spouses] they are both residents at facility, plan for residents to transition back to ALF (assisted living facility). Review of a Discharge summary, dated [DATE], showed, Resident discharged to upstairs apartment. Resident assisted by CNAs (certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of Resident #18's admission Record revealed she was admitted to the facility on [DATE], with diagnoses to include major depressive disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the PASARR Level I Screen, dated 6/30/21, Section I - Decision Making A. and B, revealed it was not completed to reflect Resident #18's mental illness. During an interview on 09/19/23 at 3:00 p.m. Director of Nursing (DON) stated that Residents #18, #30 and #45's PASARRs should have been updated to show the new diagnosis of serious mental illness after admission and submitted for a Level II. The DON stated the facility had never really had a process for PASARRs before besides just reviewing them upon admission, but the facility will now develop a PASARR process. A review of the policy title, Coordination-Pre-admission Screening and Resident Review, undated showed, 2. b. Referring all Level II residents with newly evident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to revise the person centered care plan to reflect the use of the word mama to communicate and identify the needs by one resident (#37) with communication limitations of thirty-two residents sampled. Findings included: On 9/18/2023 at 7:00 a.m. Resident #37 was observed laying down in bed dressed in her nightgown, with her bedside table next to her bed. Resident #37 was not able to communicate when she was asked questions. On 9/20/2023 at 3:45 p.m. Resident #37 was observed laying down in bed dressed in her nightgown, trying to express herself, but was unable to communicate her needs. A review of the admission Record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, altered mental status, unspecified and adult failure to thrive. A review of the Minimum Data Set (MDS), 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 accommodations were in place related to visual impairment for one resident (#47) out of thirty-two sampled residents. Findings included: An observation was made on 9/19/23 at 4:59 p.m. of Resident #47 sitting in her wheelchair next to her bed. The resident's dinner tray was in front of her, and the drinks were open, but the resident said she didn't know what she was served. The resident also said she did not know where her drink was on the tray and wanted to be told where it was located, she said she was unable to see what was on her tray. Review of admission Record showed Resident #47 was admitted on [DATE] with diagnoses including unspecified glaucoma, and age-related physical debility. Review of Resident #47's quarterly Minimum Data Set (MDS,) dated 6/16/23, Section C - Cognitive Patterns, showed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating she has moderately impaired cognition. Section B -…

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, record review and interview the facility failed to provide nail care related to trimming and cleaning fingernails for one resident (#7) of thirty-two residents. Finding included: On 09/18/2023 at 10:00 a.m. and 3:00 p.m. Resident #7 was observed lying down in bed dressed in a nightgown, hair disheveled, facial hair on his face and long fingernails. On 9/19/2023 and 9/20/2023 at 11:00 a.m. and 4:00 p.m. Resident #7 was observed lying down in his bed, hair disheveled, facial hair on his face and long fingernails. A review of Resident #7's admission Record revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to hepatic encephalopathy, unspecified macular degeneration, anxiety disorder, and depression. A review of the Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns showed a Brief Interview for Mental Status score of 13 indicating Resident #7 was cognitively intact. Further review of the MDS Section G- Functional Status revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure one resident (#41) of two residents reviewed for respiratory services was administered oxygen at the physician ordered flow rate. Findings included: An observation, on 09/18/23 at 10:35 a.m. showed Resident #41 was alone in her room sitting up in bed and looked distressed with a frown on her face. Resident #41 was observed being administered oxygen via a nasal cannula. During an immediate interview on 09/18/23 at 10:35 a.m. Resident #41 shook her head no (side to side) when asked if she was ok. Resident #41 shook her head yes (up and down) when asked if she was short of breath. Resident #41's oxygen concentrator was observed to be set for an oxygen flow rate of one liter per minute. (Photographic Evidence Obtained) During an interview on 09/18/23 at 10:37 a.m. Staff A, Licensed Practical Nurse (LPN) stated Resident #41 had COPD (chronic obstructive pulmonary disease) and when Resident #41 gets short of breath she gets anxious. Staff…

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, record review and policy review the facility failed to ensure proper infection control practices were implemented for two (#42 and #209) out of two residents on isolation precautions out of a total of thirty-two residents sampled. Findings included: 1. An observation was made on 9/18/23 at 7:18 a.m. of a Contact Precautions sign on the door of Resident #42. There was no personal protective equipment (PPE) cart placed outside the door. On 9/18/23 at 8:35 a.m. an unknown staff member was observed in the resident's room without PPE. An observation was made on 9/18/23 at 4:25 p.m. of Staff I, Licensed Practical Nurse (LPN) standing at Resident #42's bedside with no PPE on. The Contact Precaution sign was still posted on the door. Upon exiting the room an interview was conducted with Staff I, LPN. Staff I, LPN confirmed there was no PPE cart outside the room and no PPE set up inside the room. When asked if staff were not wearing PPE to go in Resident #42's room he said, No not really.…

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, interviews, and policy review facility did not ensure the call bell system was accessible to eleven residents (#28, #47, #13, #16, #15, #41, #54, #40, #26, #5, #4) out of thirty-two residents sampled and did not ensure a call system was accessible at one toilet out of twenty-two toilets in resident rooms. Findings included: 1. An interview was conducted on 9/18/23 at 1:30 p.m. with Resident #28. The resident was sitting in a wheelchair on the left side of her bed. The resident said her call light was on the other side of the curtain by her roommate and she couldn't reach it when she needed to. She said she needed help previously and wasn't able to call and just had to wait for someone to come in. Resident #28's call light was observed to be past the curtain on the right side of her bed without a string. (Photographic Evidence Obtained) Review of the admission Record showed Resident #28 was admitted to the facility on [DATE]. Review of Resident #28's annual Minimum Data Set (MDS), 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 record review, staff interview, and review of facility policy, the facility failed to provide the resident or representative with detailed written notice of discharge and hospital transfers for two (#6, #35) of two residents reviewed for discharge. Findings included: 1. Review of the Electronic Medical Record (EMR) 'Face Sheet' revealed Resident #6 was originally admitted to the facility on [DATE]. Further review of the EMR Census Tab revealed Resident #6 was transferred to the hospital on [DATE]. Additional review of the EMR revealed a nurse progress note dated 08/29/21 at 07:39 a.m. documenting a telephone message left for Resident #6's spouse requesting a call back related to the transfer of Resident #6 to the hospital. Further review of the paper record revealed an Agency for Health Care Administration (AHCA) form 3120-0002 Revised May '01 partially completed on 8/29/21 with under Notice received by: [name of resident#6's spouse] at the signature space verbal consent given and the signature of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to provide the resident or representative documentation of the facility's bed hold policy for two (#6, #35) of two residents reviewed for discharge. Findings included: 1. Review of the Electronic Medical Record (EMR) 'Face Sheet' revealed Resident #6 was originally admitted to the facility on [DATE]. Further review of the EMR Census Tab revealed Resident #6 was transferred to the hospital on [DATE]. Additional review of the EMR revealed a nurse progress note dated 08/29/21 at 07:39 documenting a telephone message left for Resident #6's spouse requesting a call back related to the transfer of Resident #6 to the hospital. No additional evidence was present in the clinical record related to the provision of bed hold information. 2. Review of the EMR 'Face Sheet' revealed Resident #35 was originally admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Additional review of the EMR revealed a skilled…

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 policy review, the facility failed to post Nursing Staffing information that included all the required elements on two of three days observed. Findings included: Posted Staffing Data was observed on 09/08/21 at 2:45 P.M. at the Nurses' Station of the facility. The posting was dated 09/08/21; numbers of staff by discipline and shift were posted however the column titled 'actual hours' was blank. Photographic evidence was obtained. Posted Staffing Data was observed on 09/09/21 at 09:21 A.M. at the Nurses' Station of the facility. The posting was dated 09/09/21; numbers of staff by discipline and shift were posted however the column titled 'actual hours' was blank. Photographic evidence was obtained. During an interview conducted with the Nursing Home Administrator (NHA) on 09/09/21 at 12:29 P.M., the NHA stated staffing numbers are completed by the Staffing Coordinator and posted daily. The posting was reviewed with the NHA, and she confirmed no data was entered or posted relating to actual hours worked. The NHA stated 'actual hours' were completed…

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, staff interview, and review of food and nutrition services documentation, the facility failed to hold cold Time/Temperature Control for Safety (TCS) food at 41 degrees Fahrenheit (F) or below during refrigerated storage during 2 observations, hot food at 135 degrees F or above during holding on the steam table for the breakfast meal, and maintain four kitchen utensils in good condition. The findings included: 1. During the Initial Kitchen tour on 09/08/21 at 9:39 AM, the walk in refrigerator temperature was reading 46 degrees F on dial thermometer closest to the entrance of the refrigerator. The thermometer was not located in the warmest part of the refrigerator unit. Photographic evidence obtained. There was another dial thermometer further back in the walk in refrigerator on the same side that was reading 50 degrees F. Photographic evidence obtained. The refrigerator fans were operating at the time. There were no staff going into the walk in refrigerator at the time and the walk in was well stocked with food. The temperature log for the walk in refrigerator…

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 behavioral monitoring related to psychotropic medications was performed for one resident (#13) of five residents reviewed for unnecessary medications. Findings included: A record review for Resident #13 revealed an admission date of 01/08/2021 and diagnoses that included Bipolar Disorder, Dementia, Major Depressive Disorder and Anxiety as per the admission face sheet. The 5-Day Minimum Data Set (MDS) dated [DATE] showed; Section C, Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment; Section I, diagnosis of Anxiety, Depression, Bipolar Disorder and Psychotic Disorder were all checked 'yes'; and Section N, antipsychotics, antianxiety and antidepressants were received during 7 of the past 7 days. Review of the Care Plan revealed a focus of: The Resident uses antipsychotic, anxiolytics, and antidepressant medications (initiated 01/20/2021), with interventions that included; administer…

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.