Vero Beach Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observations, interviews and record reviews, the facility failed to provide a safe, sanitary and comfortable environment for residents, staff and the public, in the common areas on 4 of 5 units ([NAME], Canterbury, [NAME], and [NAME]). The findings included: 1. There was an accumulation of dust and mold-like substance in the air condition vents and ducts on the [NAME] Unit, the Canterbury Unit, the [NAME] Unit and the [NAME] Unit, as well as the common areas and dining areas of the units. 2. In the Shower room on Canterbury unit, there was a large puddle of water on the floor at the commode, the toilet was running, the wall under the shower on the left side of the room was damaged, there was an accumulation of dust on the inside of the air conditioning vent and duct. 3. In the soiled utility room on the Canterbury unit, the wall was damaged inside of entrance to the room, and there was a sink filled with standing dirty water. 4. The wall in the employee bathroom of the [NAME]…

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 honor resident's choice to sleep in and utilize a reclining chair for 1 of 7 reviewed for choices, Resident #138. The findings included: Review of Resident #138 medical records revealed the resident had multiple admissions with the latest admission on [DATE]. He has diagnoses that included Lymphedema, Chronic Systolic Congestive Heart Failure, Venous Insufficiency, Chronic Kidney Disease, Anxiety Disorder, Depression, Dyspnea, and Severe Morbid Obesity. His MDS (Minimum Data Set) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicting cognition is intact. Review of the physician Progress Notes on 09/12/24, with a service date of 09/10/24, revealed the physician documented the resident is not being compliant with elevating his legs during the day, but he is wearing compressive ACE wraps. He documented he has given up on trying to get a recliner chair for his room which would assist in elevating his legs. He was trying 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.

Based on interviews and record reviews, the facility failed to promptly act on and resolve grievances voiced by residents and the Resident Council, for 8 of the residents interviewed, including Residents #113, #85, #143, #13, #122, #27, #95, and #60. Four of 4 residents in the Resident Council meeeting voiced food concerns that included Residents #85, #113, #116 and #135. The census at the time of the survey was 146. The findings included: Record review of Resident #113's most recent Minimum Data Set (MDS) assessment documented Resident #113, with a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. An interview was conducted on 09/09/24 at 10:17 AM with Resident #113, the Resident Council President, who when asked of any grievances that had not been resolved by the facility, replied that grievances related to food were ongoing and had not been resolved. During the interview, Resident #113 granted permission to this Surveyor to review Resident Council Meeting Minutes and Food Committee Meeting minutes. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to ensure 1 of 1 sampled resident was free from physical restraint, Resident #128. The findings included: Review of the policy, titles, Identifying Seclusion and Unauthorized Restraint, revised 06/2023, documented, in part, As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify involuntary seclusion and/or unauthorized restraint of residents. Unauthorized Physical Restraints: 1. Residents are free from the use of any physical restraints not required to treat their medical condition. 2. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: a. Is attached or adjacent to a resident's body; b. Cannot be removed easily by the resident (in the same manner as it was applied by the staff); and c. Restricts the resident's freedom of movement or normal access to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure accurate assessments for 2 of 42 sampled resident records reviewed, Residents #48 and #60, as evidenced for Resident #48 related to visual impairment and Resident #60 for use of antianxiety medications. The findings included: 1. Review of Resident #48 medical records revealed Resident #48 was admitted to the facility on [DATE] with diagnoses tha included Heart Failure, Hypertension, Diabetes Mellitus, and Major Depressive Disorder. Review of the resident's care plan initiated and revised on 03/10/23 documented the resident is at risk for complications and impaired visual function related to dry eyes syndrome and complications of Diabetes. The interventions included to observe for and report to the nurse any complaints of eye discomfort / pain, any noted problems with or any complaints of change in eyesight. To report and document as needed (PRN) any signs or symptoms of acute eye problems: Change in ability to perform ADLs [Activity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to develop and implement care plans for 1 of 3 sampled residents related to behaviors reviewed for catheter, Resident #91, and the facility failed to develop and implement care plans to accurately account for vision deficit for 1 of 2 sampled residents reviewed for vision, Resident #48. The findings included: 1. Record review revealed Resident #91 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Resident #91's diagnoses at the time of the assessment included: Heart Failure, Hypertension, Obstructive Uropathy, Diabetes Mellitus, Hemiplegia, History of cerebral infarction, Retention of urine, and Adult failure to thrive. Resident #91 was not interviewable. Review of Resident #91's orders included: On 01/06/24, Indwelling Urinary…

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 revise care plans for 2 of 9 sampled residents reviewed for nutrition and or medication use, Residents #81 and #79, as evidenced by the care plan for Resident #81 lacked information related to being aggressive toward others, and the care plan for Resident #79 noted the resident had a fluid restriction order that had been discontinued. The findings included: 1. Review of the record revealed Resident #81 was admitted to the facility on [DATE]. Further review revealed the resident was moved to different rooms on 04/20/24 and 09/04/24 after a resident-to-resident altercation. Review of the current care plans lacked any documentation related to physical aggression or any resident-to-resident events or conflicts. During an interview on 09/12/24 at 2:01 PM, the Director of Nursing (DON) agreed Resident #81 had had two resident-to-resident events and was surprised this was not noted in any of the care plans. During an interview on 09/12/24 at 2:32 PM, 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, the facility failed to provide services of peri care and failed to get a resident out of bed as requested for 1 of 1 sampled resident, Resident #44, reviewed for Activities of Daily Living (ADLs). The findings included: Clinical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnosis that included: medically complex conditions. The admission Minimum Data Set (MDS) assessment, reference date 09/03/24, recorded a Brief Interview for Mental Status score of 14, indicating Resident #44 was cognitively intact. This MDS evidenced Resident #44 exhibited moods that included: Feeling down, depressed, or hopeless. Poor appetite or overeating. Feeling bad for herself - or that she is a failure or have let herself or her family down. This MDS also documented Resident #44 required substantial / maximal assistance with toileting hygiene, shower / bath self, and lower body dressing, and required partial / moderate assistance with upper body dressing. Additional review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and Hospice Agreement review, the facility failed to ensure coordination of care and services for 2 of 2 sampled residents, as evidenced by the lack of orders for Hospice services and oxygen use for Resident #25; and failure to coordinate the provision of an offloading boot, lack of Certificate of Terminal Illness (CTI) paperwork, and lack of current Hospice notes for Resident #87. The findings included: Review of the Hospice Agreement effective 01/15/24 documented, 6a. Patient admission Process: 1. ii. 3. Hospice shall notify Home, as appropriate, of patients being admitted to service, the day of the referral. Hospice shall provide copies of the Initial Hospice admission paperwork. 8. Coordination, Supervision and Evaluation of the Care/Service: . b. Home Responsibilities . iv. Home shall assist the Hospice in the coordination of patient care from admission up through and including discharge from service. 1) Review of the record revealed Resident #25 was admitted…

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 follow their fall prevention policy for initiating new interventions, updating care plans, and ensuring supervision to prevent falls for 1 of 4 sampled residents reviewed for accidents (Resident #128). The findings included: Review of the policy Falls - Managing, Preventing, and Documentation revised 01/2024 documented, Standard: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Guideline: The resident's plan of care will be developed and followed accordingly to prevent or minimize the risk of falls or fall related injuries. Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to secure medication storage on 2 of 5 units, as evidenced by leaving the medication and treatment carts unlocked and unattended on the [NAME] Unit, the designated memory care unit, and a random observation of non-secured ointments on the [NAME] Unit. The findings included: 1) An observation on 09/09/24 at 11:43 AM revealed the medication cart was positioned against the wall in the common area of the [NAME] unit, unlocked with at least three bubble pack medication cards with pills in at least one pack, noted on top of the cart. Staff K, Licensed Practical Nurse (LPN) was noted at the desk on the other side of the common area, working on the computer. The LPN retrieved the bubble pack medication from the medication cart, but left the medication cart unlocked (Photographic Evidence Obtained). During the continued observation on 09/09/24 at 12:01 PM, both the medication cart and the treatment cart remained unlocked in the common area. Although three staff were…

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, interview, and policy review, the facility failed to ensure complete and current medical records for 3 of 42 sampled residents (Resident #5, #26 and #81). The findings included: Review of the policy Documentation revised 01/2024 documented, Procedure: . 2. The following information is to be documented in the resident medical record: . c) Treatments or services performed; 1) During an observation on 09/09/24 at 10:41 AM, Resident #5 was noted with thick elongated toenails. The resident reported he had not been seen by a podiatrist. Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the electronic medical record lacked any documented podiatry services. During an interview on 09/12/24 at 4:44 PM, when asked about podiatry services for Resident #5, the Social Services Director (SSD) stated the resident had been seen by the podiatrist. When asked to locate and provide evidence of the services, the SSD was unable to locate any documented podiatry service…

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 client's Arbitration agreement and interview, the facility failed to ensure the arbitration agreement is explained to the resident or representative in a manner they understand, and had a signature from the resident if they agreed to the arbitration agreement, for 2 of 3 residents reviewed for Arbitration (Resident #149 and Resident #143). The findings included: During the initial entrance conference on 09/09/24 at 9:17 AM, the surveyor requested a list of residents who currently reside in the facility and entered into a binding arbitration agreement. On 09/11/24 Surveyor was given a list of residents that have a Y or a N next to their name. Surveyor chose three residents that were recently admitted to the facility with a high BIMS (Brief Interview for Mental Status) to interview. A review of Resident #149 medical records revealed this resident is on the Rehab unit (SSU) and admitted to the facility on [DATE]. Her 5-day Medicare MDS (Minimum Data Set) documents her BIMS (Brief Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to maintain a functioning call system for 1 of 26 sampled residents, Resident #27; and failed to maintain a call light in a manner to be accessible to the resident for 1 of 26 sampled residents, Resident #95. The findings included: 1. Record review revealed Resident #27 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitive was intact. During an interview with Resident #27, on 09/10/24 at 9:20 AM, and the surveyor requested Resident #27 to initiate the call system by pressing a button at the end of the call light cord. Resident #27 pressed the button and there was no light over the door to indicate that the resident had initiated the call light and no signal at the nurse' station to indicate that Resident #27 had initiated the call light. At the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to provide a safe, clean comfortable homelike environment for the residents. The findings included: A tour of the facility, including resident rooms, was conducted on 07/08/24 at 9:30 AM and a second tour was conducted on 07/10/24 on 12:00 PM, with the Maintenance Director and the Housekeeping Manager. They both acknowledged the following concerns that were identified had during tour: Photographic Evidence Obtained. a. room [ROOM NUMBER] A - The wheelchair arm rests, seat and back of chair were torn. b. room [ROOM NUMBER] - The floor was very dirty with debris that included the corners of the room. room [ROOM NUMBER] - The resident in bed-A stated on 07/08/24 at 9:55 AM that there had been an Ibuprofen pill on the floor that gets pushed around, which has been there a month, and it just gets moved around when they clean and mop. She said they don't clean the toilet and it is filthy with dried up bowel movement. She stataed she has told…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure nursing staff followed physician orders for blood pressure medication perimeters for 1 of 5 sampled residents (Resident #2) reviewed for medications; and failed to follow physician orders for a wound vac for 1 of 1 sampled resident reviewed for a wound vac (Resident #4) The findings included: 1. Record review for Resident #2 revealed Resident #2 was admitted to the facility on [DATE] with diagnoses to include Hypertension (high blood pressure), Orthostatic Hypotention, Atrial Fibrillation, and History of Falling, Review of the physician orders revealed the following orders: a) Dilltiazem HCl Oral Tablet 30 MG to give 0.5 tablet by mouth every 6 hours for Hypertension. Hold if SBP(Systolic Blood Pressure) is less than 105 or HR (Heart Rate) is less than 60 (0000-midnight, 6:00 AM, 12:00 PM, and 6:00 PM). b) Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for Hypertension. Hold for SBP [Systolic…

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 interdisciplinary team (IDT) participation in care planning process for 7 of 32 sampled residents, to include food and nutrition services, activities, and therapy, as applicable involving Residents #6, #22, #41, #106, #111, #5, and #8. The findings included: On 07/13/23 during the afternoon, Staff B, Minimum Data Set (MDS) Coordinator, provided requested evidence of interdisciplinary team (IDT) participation in the care planning process for numerous resident's in the survey sample, as the electronic medical record lacked current participation records. An overview of the provided Quality Resident Review Worksheet & Attendance Records, the forms utilized by the facility to document participation in the care planning process, revealed numerous blanks where the signatures of dietary, activities and therapy staff were to be recorded. The MDS Coordinator confirmed the Registered Dietician was only in the building once weekly, and also agreed someone…

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 staff failed to speak to 4 of 32 sampled residents in a dignified manner, related to toileting and care, use of cell phones by staff during care, and staff speaking in foreign language during care, Residents #21, #22, #41, and #109. The findings included: 1. Review of the record revealed Resident #21 was admitted to the facility on [DATE], and moved to her current room on 07/19/22. Review of the current Minimum Data Set (MDS) assessment, dated 04/30/23, documented Resident #21 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident did not exhibit any behaviors, and needed the extensive to total assistance from staff for all Activities of Daily Living (ADLs), except eating. This MDS documented locomotion on the unit only occurred once or twice during the seven-day look back period. During an interview on 07/10/23 at 11:04 AM, Resident #21…

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 baths and showers for 2 of 5 sampled residents were provided as per facility schedule and resident request, Resident #22 and #100. The findings included: 1. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE], documented the resident had a BIMS score of 10, on a 0 to 15 scale, indicating he had some cognitive impairment. This MDS documented the resident had no behaviors, and that he needed the total assistance of one person for bathing. This MDS also documented it was very important for the resident to choose between a bath and a shower. During an interview on 07/10/23 at 3:12 PM, Resident #22 and his wife were discussing their concerns with the slow or no response by staff, resulting in the resident having incontinent episodes. The resident's wife stated, They don't like giving showers. You have to beg for them. You always get the yes, yes, yes, but nothing…

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 housekeeping and maintenance services to maintain a clean, comfortable and homelike environment for 3 of 5 units (Units 100, 200, and 500); and failed to maintain the residents' call lights to be accessible to the residents, for 4 of 53 sampled residents reviewed, Residents #64, #46, #4 and #85. The findings included: 1. Observations on 07/13/23 at approximately 1:00 PM, accompanied with the Director of Maintenance, revealed the following: In room [ROOM NUMBER], the room floors were dirty, the bed linens on the window-bed were stained, there was no toilet seat on the commode, there was an accumulation of trash on the floor, and the commode was not in proper working order. As reported by the residents, the toilet would 'fill up with water and then go down really slow'. In room [ROOM NUMBER], the privacy curtain between the beds was stained, there was an accumulation of residue and debris on the floor and the sink in the shared…

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 document review, the facility failed to initiate a new wound care physician order in a timely manner for 1 of 3 sampled residents reviewed for facility-acquired pressure ulcers, Resident #33. The findings included: The policy, titled, Prevention of Pressure Ulcers/ Injuries and revised on 07/17, documented, in part: Review the interventions and strategies for effectiveness on an ongoing basis. Resident #33 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Type 2 diabetes, history of falls, Atrial Fibrillation, Tremors, Glaucoma, Hyperlipidemia, and muscle wasting with atrophy. The record documented the resident had a BIMS (Brief Interview for Mental Status) score of 3 of 15, which indicated severe cognitive impairment. On 07/10/23 at 11:53 AM, a telephone interview was conducted with the spouse of Resident #33 to review his care at the facility. She stated her husband has a pressure ulcer on his left heel and she was the one who identified it. She 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician dietary orders and recommendations for obtaining weights for 3 of 5 sampled residents reviewed for nutrition, Residents #120, #111 and #123, that resulted in significant weight loss for Residents #111 and #123. The findings included: The facility's policy, titled, 'Weight Assessment and Intervention', revised September 2022, documented, in part: Weight Assessment 1. The nursing staff will measure resident weight on admission. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Any weight change of 5% or more since the last weight assessment will be retaken as soon as practical usually within the next day for confirmation. If the weight is verified, nursing will communicate with the Dietitian. 3. The Dietitian will review the Weight Record to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for…

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 respond to 1 of 1 sampled residents reviewed for vocalization of significant pain which resulted in harm, Resident #36. The findings included: The facility policy, titled, Pain Assessment and Management, documents in part: 2) Pain management is defined as the process for alleviating the resident's pain to a level that is acceptable to the resident and is based on his or clinical condition and established treatment goals. 3)d address the underlying cause of the pain Resident #36 was admitted to the facility on [DATE] with documented diagnosis to include Dementia, unspecified severity with other behavioral disturbance, history of falling, Osteoarthritis, personal history of Covid 19, and Dysphagia. The resident had a BIMS (Brief Interview for Mental Status) score of 3 of 15, which indicates severe cognitive impairment. Record review of the nursing progress notes for Resident #36 documented on 03/10/23 at 1:03 PM that the resident 'has been in bed all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care and services for 1 of 1 sample resident receiving dialysis, as evidenced by a lack of consistent documentation of coordination between the nursing and dialysis facility; failure to ensure documented pre and post weights to monitor for fluid overload; and failure to inform the physician and/or family of the resident's refusal of dialysis services, Resident #6. The findings included: Review of the record revealed Resident #6 was admitted to the facility on [DATE]. Resident #6 received dialysis services from an outside facility every Monday, Wednesday, and Friday. Dialysis treatment records were noted as part of the record to ensure communication between the two facilities. Review of the record lacked any communication documentation from the dialysis facility for the month of June 2023, and only included one note dated 07/10/23 for the month of July 2023. On 07/12/23 at 1:30 PM, Staff R, Unit Manager, explained the documented communication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to follow physician orders for 2 of 2 sampled residents with physician ordered fluid restrictions, Residents #22 and 120. The findings included: The facility's policy, titled, 'Fluid Restrictions' documented, in part: Policy Interpretation and Implementation 1). When a physician prescribes a fluid restriction, a communication form notifying the Fod and Nutrition Services department will be completed. 2). If the resident is receiving liquid nourishments for nutritional support. 3). If no clarification of liquid nourishment provided is obtained the liquid nourishment shall be included in the total fluids administered. 4). Water pitchers will be removed from the resident's room. Beverage preferences will be obtained by Food and Nutrition Services designee if possible and reflected on the resident's meal ticket/tray card. 5). Jell-O, ice cream, soup and anything at room temperature that becomes liquid, will be calculated and included in 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 and interview the facilty failed to serve food in a sanitary manner, according to the food service safety. The Findings Included: On 03/07/22 at 9:28 AM, Conducted an intial brief kitchen tour,accompanied by the Certified Dietary Manager. The following was observed. (1) During the inspection of the walk in refrigerator there was eighteen half pint container of 2% milk, dated 3/2/22. (2) The janitor closet had the broom sitting on the floor sink that was very dirty, and had not been cleaned for a number of weeks. (3) The dry storage room had disposable cups that was not wrapped or place in a bag. (4) The stove drip pan, under the stove burner, was dirty with dried up food. (5) The wall of the oven need cleaning there was black specks all over it. (6) The floor under the oven was dirty, and had not been cleaned for awhile. (7) The dumpster is very dirty and rusted. On 3/7/22 at 10:45AM during a interview with the Certified Dietary Manager, she was informed of the findings. On 03/09/22 at 9:59 AM, an interview was conducted with the Regional Food Service Director.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to provide a safe, clean comfortable homelike environment and to make sure call lights are in reach for 3 of 4 units observed. The findings included: 1. A tour of the facility and resident rooms were conducted on 03/07/22 & 03/08/22, and subsequent tour was then completed on 03/09/22 at 10:00 AM with the Director of Environment, the Administrator, and previous Housekeeping Supervisor. The Environmental Director states they do deep cleaning every month doing two rooms a day. They all acknowledged the findings on the tour. room [ROOM NUMBER]-B-the chair rail is scuffed up behind bed with large patches of white caulking on top of beige color paint. The ceiling is stained in right corner of room, no light bulb in one of two lights above bed and the string to pull the light on and off is broken. room [ROOM NUMBER]-the floors are very dirty and sticky to walk on, grapes smooched on the floor, a urinal observed sitting next to a pitcher 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 record review and interview, the facility failed to ensure interdisciplinary team (IDT) participation, to include the direct care nurse and aide, a member of the food and nutrition services, and other appropriate staff as determined by the resident's need, in the care planning process for 14 of 23 sampled residents (Residents #26, #55, #65, #71, #34, #39, #7, #64, #41, #74, #45, #24, #44 and #62). The facility also failed to review and revise care plans for 3 of 23 sampled residents (Residents #55, #65, #71). The findings included: During an interview on 03/10/22 at 12:05 PM, the Minimum Data Set (MDS) Coordinator, who was responsible for the interdisciplinary care planning process, was asked who was participating in the care planning process on a quarterly and annual basis. The MDS Coordinator stated recently it has been just her and the two social services staff. The MDS Coordinator explained she keeps a record of the care plan meetings and participation on the resident's Care Conference Record. 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 an ongoing activity program for 8 of 8 sampled residents (Residents #9, #7, #48, #8, #55, #64, #74, #45). The findings included: 1) Observation was conducted on Resident #7, #64, and #74 on 03/07/22 at 9:24 AM whereas Resident #7 and #64 was observed sitting in their wheelchair, in the common resident's area on the [NAME] unit (the memory care unit). There was no activity being provided, there was no stimulation. Resident #7 put his head down sleeping. Resident #64 was sitting in the wheelchair next to the exit door across the medication cart, she put her head down, sleeping. Resident #74 was wandering around the [NAME] unit. On 03/07/22 at 10:25 AM another observation was conducted on the [NAME] unit, 7 residents including Resident #7 and Resident #64 were observed in the resident common area, they were sitting in their wheelchair, all put their heads down, sleeping, there was no activity, no stimulation for the residents. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility assessment review, the facility failed to ensure sufficient nursing staff to ensure provision of timely care for 3 of 23 sampled residents interviewed (Residents #71, #65, and #26); failed to ensure the provision of activities; failed to ensure proper care planning; failed to provide showers (Resident # 27 and Resident #44), and as evidenced by the usage of managerial staff to cover direct care shifts. The findings included: Review of the Facility Assessment updated on 01/01/22 and reviewed with the Quality Assurance Committee on 01/25/22 documented the following staffing needs for an average daily census of 94 to 98 residents: Licensed Nursing: A Director of Nursing which the facility had. An Assistant Director of Nursing which the facility did not have. An RN (Registered Nurse) Unit Manager for the rehabilitation/high acuity unit which the facility did not have. A Long Term Care RN Unit Manager. The facility had a Licensed Practical Nurse (LPN) Unit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide showers upon request and schedule for for 2 of 5 sampled residents for choices (Residents #27 & #44). The findings included: 1. During an interview on 03/07/2022 at 10:11 AM with Resident #27, she states she has not had a shower in a while. The CNAs tell her they have 27 residents to take care of and they don't have time to give me a shower. Review of the resident record revealed Resident #27 was admitted on [DATE] with a diagnosis to include Chronic Obstructive Pulmonary Disease (COPD), Malignant Neoplasm, Anxiety, Adult Failure to Thrive, Polyneuropathy, and Corneal Ulcer. Review of her quarterly MDS (Minimum Data Set) dated 01/03/22 reveals she has a BIMS (Brief Interview Mental Status) score of a 15 which means her cognition is intact. She is extensive assist one person for personal hygiene, dressing and transfers. Her functional status includes Physical Help in bathing with one person assist. Review of her Care Plan documents the resident…

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

Based on interview and inability to review resident personal funds accounts, the facility failed to ensure availability of personal funds for 1 of 1 sampled resident (Resident #26). The findings included: During an interview on 03/08/22 at 9:49 AM, Resident #26 stated she had not been able to get any money from her personal funds account with the facility since the change in ownership. When asked what the facility staff said to her when she asked for some money, Resident #26 stated they ask, What do you need the money for? Resident #26 stated she needs some shoes and needs to pay her cell phone bill. When asked if the facility staff told her when she could get some money, Resident #26 stated they have not told her, but she overheard a staff person talking about residents being able to get money on the 15th of the month. Resident #26 stated she tried to get the money last week. During an interview on 03/10/22 at 10:29 AM, the Business Office Manager (BOM) explained the process for a resident to get money from their personal funds account would be to get petty cash for amounts of $50…

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, interview, and policy review, the facility failed to ensure consistency in the record related to the code status (documentation that directs staff to provide or hold cardiopulmonary resuscitation/CPR), for 1 of 1 sampled resident. A Do Not Resuscitate (DNR) request had been requested by Resident #71, and the yellow copy for emergency personnel had been executed, but the physician's current orders documented Resident #71 as a Full Code status. The findings included: Review of the record revealed Resident #71 was admitted to the facility on [DATE] with a code status of full code, indicating if the resident's heart would stop or the resident stopped breathing, cardiopulmonary resuscitation (CPR) would be conducted by the facility staff. Further review of the record revealed a yellow copy of the Do Not Resuscitate Order signed by Resident #71 and the physician that was dated [DATE]. Review of the current physician orders documented the code status for Residents #71 as a full code since 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 , record review and interview the facility failed to develop and implement care plan for Activities, and for the use of Diuretic medicaiton, for 3 of 23 sampled Residents (Residents #8, 9 and 42). The Findings included: 1) Resident #8 was admitted to the facility on [DATE].Brief interview for Mental Status, (BIMS) score is 13.TheResident pertinent diagnosis is Metabolic Encephalopathy unspecified Sequelae of cerebral infraction. The Minimum Data Set Assessment (MDS) was completed on 12/14/21. On 3/8/22 at 2:01PM The Resident observed in bed for the pass 2 days. The Resident state that he did not have activities. Record review of the Resident Electronic Medical Chart revealed that Resident #8 did not have a Care Plan for Activities. ON 03/10/22 02:22 PM conduct interview with the MDS Coordinator she informed me that the Resident care plan for activities was never developed. 2) Resident #9 was admitted on [DATE]. His Minimum Data Set Assesment (MDS) was completed on 12/15/21. Pertinent…

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 assistance with eating for Resident #34 who had significant weight loss, for 1 of 4 sampled resident. The findings included: On 03/08/22 at 11:49 AM Resident #34 was observed with the lunch tray in front of her, she did not touch the food, she was not being provided assistance with feeding. Resident #34 was severely confused and not aware of what to do with the food. On 03/10/22 at 11:44 AM another observation was made on Resident #34 during lunch time. The food tray was observed in front of her, she did not touch the food, including the peanut butter and jelly sandwich. Resident #34 was staring at the food on the tray, she was very confused, she did not know what to do with the food, no one was assisting her with eating. When asked, Staff A, a certified nursing assistant was someone supposed to be providing assistance to Resident #34 with feeding, Staff A stated, Resident #34 was supposed to be feeding herself independently, she did…

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 personnel file review and interview, the facility failed to ensure annual evaluations were completed for 3 of 3 sampled Certified Nursing Assistants (Staff G, H, and I). The findings included: On 03/10/22 at 4:23 PM, Personnel files were reviewed with Human Resources (HR) and the Regional HR Manager. Surveyor had requested to see annual staff evaluations, they were unable to locate any in the files they had on hand but stated that the DON (Director of Nursing) would be responsible for completing the evaluations. They acknowledged that the files and the annual evaluations are not up to date. The Regional HR Manager explained that with the change in ownership on 03/01/22, they did not have the complete files, all staff had a new starting date of 03/01/22. Surveyor requested to see a Policy & Procedure for doing evaluations but was advised they do not have one. A side-by-side review of the personnel files for Staff A, a Certified Nursing Assistant (CNA) who was originally hired on 02/26/13, Staff J, a CNA who was originally hired on 08/24/16; and Staff K, a CNA who was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly secure medication for 2 of 4 units ([NAME] and [NAME]). The findings included: 1. On 03/07/22 at 11:17 AM the [NAME] medication cart was observed parked in the hallway, it was left unlocked and unattended, the nurse was sitting at the nursing station, away from the medication cart. There were 7 residents on the unit at the time, there was a resident sitting immediately across from the medication cart. The surveyor observed the medication cart, the nurse did not acknowledge if the medication cart was left unlocked. At 11:23 AM the surveyor informed the nurse the medication cart was left unlocked; she then gets up and locked it. This was on the memory care unit which has 5 residents who were independently ambulatory with confusion. Resident # 35, the quarterly minimum data set (MDS) assessment reference date 01/08/22 indicated Resident #35 had brief interview for mental status (BIMS) score of 00 for severely cognitively impaired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an as needed (PRN) antianxiety medication is limited to 14 days, with documented appropriateness for use, and with a documented duration, for 1 of 5 sampled residents (Resident #65). The findings included: Review of the record revealed Resident #65 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #65 received an antianxiety medication 3 of 7 days during the look back period. Review of the record revealed a current order dated 02/19/22 for the antianxiety medication Xanax 0.5 mg (milligrams) to be given every 12 hours as needed. This order had a documented end date of Indefinite. Further review of the record revealed a previous order dated 01/21/22 for the Xanax 0.5 mg to be given every 24 hours as needed, again with an Indefinite end date. This order was discontinued on 02/19/21, twenty-nine days after the order was written. During an interview on 03/10/22 at 5:48…

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, review of completed COVID-19 staff testing, and the county level of community transmission, the facility failed to ensure twice weekly COVID-19 testing for the current past four weeks for the 18 unvaccinated staff of the 92 total staff (weeks of 02/13/22, 02/20/22, 02/27/22 and 03/6/22). The findings included: During an interview on 03/07/22 at 3:30 PM, the Director of Nursing, who was also the Infection Control Preventionist (ICP) was asked the current COVID-19 testing schedule. The DON/ICP stated they were testing all staff once a week on Mondays. The DON/ICP was asked to provide evidence of the county level of community transmission for the past four weeks along with evidence of when they tested. The DON/ICP stated they are doing routine staff testing at the present as they are not in outbreak mode (have not had a positive result). Review of the list of current staff revealed there were 18 unvaccinated staff out of a total of 92 staff. Review of the COVID-19 line lists documented the last COVID-19 positive resident was on 01/27/22 and the last positive 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, record review and interview the facility failed to ensure a functional and appropriate call bell for Resident #82. The findings included: During an initial tour of Resident #82's room on 03/07/22, the resident's call bell was noted behind the bed, and not in reach of the resident. It was then noted that the red button to call light wass not functioning, it does not push in. Resident #82 was noted with contractures to both hands. The Resident was asked if he could push down on the call light and he stated No. Review of Resident #82 record reveal the resident was admitted on [DATE] with diagnoses to include Parkinson Disease, Unspecified Sequelae of Cerebral Infarction, Dysarthria, Schizoaffective Disorder, Bipolar Type, Mild Intellectual Disabilities, Hypertension, Major Depressive Disorder, Contracture right & left hand, and Pseudobulbar Affect. A review of the MDS (Minimum Data Set) revealed the resident has a BIMS (Brief Interview for Mental Status) of a 9, which means moderately impaired…

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.