Holy Spirit Retirement Home

Based on record review, interview, and facility policy the facility failed to have the Medical Director at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 61. Findings include: Review of the facility document titled Quality Assurance Performance and Improvement Meeting Minutes: a. Document dated 11/13/24 lacked the signature of the Medical Director Review of the facility provided policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership dated March 2020 revealed the following individuals serve on the committee, Medical Director. The committee meets at least quarterly or more often as necessary. Interview on 5/15/25 at 09:40 a.m., with the Director of Nursing revealed the Medical Director should be at the quarterly meetings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to update the Care Plan for 1 of 17 residents reviewed. Resident #36 was admitted to Hospice on 4/16/25 and staff failed to include a focus area for the special service. The facility reported a census of 61 residents. Findings include: According to the Minimum Data Set assessment dated [DATE], Resident #36 did not have a Brief Interview for Mental Status (BIMS) assessment completed due to severe cognitive deficits. She was total dependent for dressing, hygiene, transfers and toileting. Her diagnoses included; diabetes mellitus, Alzheimer's disease, cerebrovascular accident (CVA) hemiplegia or hemiparesis, and oral dysphagia, The Care Plan updated on 4/8/25 showed that Resident #36 was on oxygen therapy, she was not able to ambulate or propel a wheel chair. The resident required 2 staff with mechanical lift for transfers and required assistance with all decision making. The Care Plan lacked a focus area for Hospice. On 5/12/25 at 11:11 AM,…

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 adequate assistance with Activities of Daily Living (ADL) for 2 of 3 residents reviewed (Resident #3 and #19.) Resident #3 required regular toileting and repositioning, she was found to be sitting in a urine saturated brief, and in her wheel chair with her legs dangling without support. Resident #19's urinary catheter was hanging on the bedrail above the bladder. The facility reported a census of 61 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 was not able to participate with a Brief Interview for Mental Status (BIMS) due to severe cognitive deficits. She was total dependent on staff for dressing, toileting and transfers. The Care Plan last updated on 5/9/25, showed that Resident #3 had self-care performance deficit with limited physical mobility. The resident had cognitive deficits, weakness and activity intolerance. She was not able to ambulate and dependent on 2-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 and record review the facility failed to adequately supervise vulnerable residents to prevent injury for 1 of 3 residents reviewed (Resident #3). Resident #3 was observed to have a bruise on her right cheek that spread up under her eye. Staff hypothesized about the cause, but were unable to fully explain the injury. The facility reported a census of 61 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #3 was not able to participate with a Brief Interview for Mental Status (BIMS) due to severe cognitive deficits. She was total dependant on staff for dressing, toileting and transfers. The Care Plan last updated on 5/9/25, showed that Resident #3 had self-care performance deficit with limited physical mobility. The resident had cognitive deficits, weakness and activity intolerance. She was not able to ambulate and dependent on 2-staff assistance with a mechanical lift for transfers. Staff were directed to use a padded foot rest under her…

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, record review, staff and resident interviews, and policy reviews, the facility failed to provide staff with current continuous positive airway pressure (CPAP) machine settings, and failed to monitor and maintain CPAP mask and tubing needs for 2 of 2 residents reviewed (Resident #8 and #42). The facility reported a census of 61. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD) and renal insufficiency.The MDS indicated Resident #8 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Observation on 5/12/25 at 1:48 PM revealed a CPAP on Resident #8's bedside table. Resident #8 reported she used the CPAP during sleep. Resident #8 reported she used the same CPAP mask and tubing since admission in June 2024. Resident #8 stated, you can tell the tubing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff and resident interviews, the facility failed to train staff to maintain properly maintain CPAP settings for resident usage for 1 of 2 residents reviewed (Resident #42). The facility reported a census of 61 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 documented diagnoses of Chronic Obstructive Pulmonary Disease (COPD), insomnia and renal insufficiency.The MDS indicated Resident #42 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Observation on 5/12/25 at 1:12 PM revealed a CPAP on Resident #42's bedside table. Resident #8 reported he used the CPAP during sleep. The Family Member reported staff set a pillow on the CPAP and they weren't certain if settings were inadvertently changed. The Family Member reported she took the CPAP to the home supplier to make certain the settings were correct. The Family…

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 record review the facility failed to ensure that staff used appropriate hand hygiene during resident cares for 1 of 3 residents reviewed, (Resident #3). The facility reported a census of 61 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #3 was not able to participate with a Brief Interview for Mental Status (BIMS) due to severe cognitive deficits. She was total dependent on staff for dressing, toileting and transfers. The Care Plan last updated on 5/9/25, showed that Resident #3 had self-care performance deficit with limited physical mobility. The resident had cognitive deficits, weakness and activity intolerance. Resident #3 had frequent incontinence, she was to be offered toileting before and after meals and with rounds at night. Her diagnoses include post-polio syndrome, intracerebral hemorrhage, type 2 diabetes, and chronic kidney disease. On 5/12/25 at 1:40 PM Staff E, Certified Nurse Aide (CNA) and Staff H, CNA transferred…

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, document review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing appropriate hand hygiene, failed to develop policies related to COVID-19 vaccinations, and not following guidelines for enhanced barrier precautions for 63 of 63 residents reviewed. The facility reported a census of 63 residents. Finding include: 1. The Minimum Data Set (MDS) for Resident #24, dated 3/18/2024 documented a Brief Interview for Mental Status of 13 indicating no cognitive impairment. The MDS documented a feeding tube present while a resident. On 5/21/24 at 7:52 AM an observation of Staff E Licensed Practical Nurse (LPN) revealed no hand hygiene prior to entering Resident #24 ' s room. Staff E entered Resident #24 ' s bathroom, obtained gloves, and applied gloves. Staff E pushed via 60 mL syringe 10 mL of tap water to auscultate for enteral tube placement. Staff E then pushed medications with a piston syringe. Staff E did not allow…

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 personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff N). The facility reported a census of 63 residents. Findings include: Review of untitled payroll information provided by the Human Resource Generalist, Employee N, Certified Nurses Assistant (CNA) date of hire recorded as 2/4/24. The date of birth revealed Staff N to be [AGE] years old at the date of hire. The personnel file for Staff N revealed the file lacked documentation of the Iowa Criminal Background Check. Review of facility provided undated policy titled Employee/Volunteer Background checks instruct high school students age [AGE] and older who seek employment or who seek employment to volunteer for positions in which they will be working with minor children, are considered adults and will be bound by the same safe…

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 Electronic Health Record (EHR) review, observation, policy review and staff interviews the facility failed to prepare food in a form designed to meet individual needs by sending incorrect consistency for modified diet ordered for 4 of 6 residents reviewed (Resident #33, #35, #39, and #44). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #33 had a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. The MDS revealed Resident #33 was on a mechanically altered diet. Review of Resident #33 ' s diet order documented a general diet with mechanical soft texture. 2. The MDS dated [DATE] documented Resident #35 had a BIMS of 13 indicating no cognitive impairment. The MDS revealed a diagnosis of dysphagia. Review of Resident #35 ' s diet order documented a low concentrated sweets diet with mechanical soft texture. 3. The MDS dated [DATE] documented Resident #39 was rarely / never understood,…

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 policy review the facility failed to store food and follow proper sanitation to prevent spread of illness in accordance with professional standards for 61 of 63 residents. The facility reported a census of 63 residents. Findings include: On 5/21/24 at 11:50 AM -12:35 PM an observation of lunch service on the 2nd floor revealed Staff F completed hand hygiene. Staff F, dietary aide picked up the tongs, removed a hamburger bun from steam table pan, placed the bun on the plate, used left hand to separate the bun, picked up the bottom of the bun in left hand, used tongs to place a hamburger patty on the bun, placed the bun and patty back on the place, placed the top bun on top of the hamburger patty with left hand, obtained small bowl with left hand, picked up scoop with right hand, scooped coleslaw into the small bowl, used right hand with tongs to pick up french fries, picked up plate with the food on it, handed it to staff in the dining room, and obtained a new plate from top of steam table. This was repeated for all plates served with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health records (EHR) review, observations, staff interview, policy review and resident family interview the facility failed to provide dignity by leaving food on a residents clothing protector as well as face to 1 of 1 resident reviewed (Resident #44). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #44 had a Brief Interview for Mental Status (BIMS) of 2 indicating severe cognitive impairment. The MDS documented Resident #44 was staff dependent during personal hygiene and substantial / maximal assistance with eating. On 5/20/24 at 1:57 PM an observation of Resident #44 sitting in her bedroom revealed 2-3 tablespoons of orange food present on clothing protector and dry orange food present on chin as well. Review of document titled, facility name SS 2024 (menu) for lunch meal on 5/20/24 revealed baked yam. On 5/20/24 at 2:10 PM Staff A, MDS coordinator stated lunch was over at 12:45 PM - 12:50 PM. On 5/22/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to refer one resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #48) reviewed for PASRR requirements. The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 documented diagnosis of anxiety disorder, depression and psychotic disorder. Review of the clinical record revealed a Notice of Negative Level I Screen Outcome dated 1/30/23 revealed the PASRR level 1 screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level 1 screening is required unless you are known to have or are suspected 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 clinical record review, observations and staff interview the facility failed to follow a care plan to provide supervision while the resident sat in a wheelchair located in his room for 1 of 21 sampled residents reviewed for comprehensive care plans (Resident #33). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 documented diagnoses of depression, muscle weakness and history of a left fracture. The MDS showed the Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of Resident #33 ' s Care Plan last revised on 5/20/24 showed on 4/2/24 the facility initiated a fall intervention for Resident #33 instructing staff not to leave Resident #33 unattended in a wheelchair while in his room. The intervention was resolved during the survey on 5/20/24. A Health Status Note dated 5/22/24 at 9:53 PM for Resident #33 documented the following: Resident #33 is high risk for fall,…

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 electronic health records review (EHR), staff interview, and observation the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not accurately measuring supplemental formula according to physician ' s order and pushing medications with a piston syringe into feeding tube for 1 of 1 residents (Resident #24). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #24, dated 3/18/2024 documented a Brief Interview for Mental Status of 13 which indicated no cognitive impairment. The MDS documented a feeding tube present while a resident. Review of Resident #24 ' s Medication Administration Record (MAR) documented 330 mL of supplemental formula to be administered per PEG tube (enteral tube) three times daily at 8:00 AM, 2:00 PM, and 8:00 PM. On 5/21/24 at 7:52 AM an observation of Staff E revealed no hand hygiene prior to entering Resident #24 ' s room. Staff E entered the bathroom, obtained gloves, and applied gloves. 10cc water auscultated for enteral tube placement.…

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

Based on observations, staff interviews, and policy review, the facility to properly store medications in a locked storage area for 1 or 1 resident observed (Resident #63). The facility reported a census of 63 residents. Findings include: 1. Observation on 5/19/24 at 2:15 p.m., revealed a bottle of Tums sitting by the sink in Resident #63 ' s room. 2. Observation on 5/20/24 at 11:05 a.m., revealed a bottle of Tums sitting by the sink in Resident #63 ' s room. Review of Resident #63 ' s clinical record lacked documentation of an assessment for Resident #63 to self administer medications. Review of the facility policy titled Conformity with Laws and Professional Standards with a revision date of April 2007 revealed the facilities policies, procedures and operational practices are developed and maintained in accordance with current and accepted professional standards and principles as well as current commonly accepted health standards established by national organizations, boards and councils. Interview on 5/21/24 at 11:54 a.m., with the Director of Nursing (DON) revealed Resident #63…

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 Electronic Health Records (EHR) review, observations, staff interview, and policy review the facility failed to provide complete and accurately documented electronic health records for 1 of 5 resident reviewed (Resident #5). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. On 5/20/24 at 9:13 AM an observation was made of resident #5 wearing oxygen in his bedroom. On 5/20/24 at 9:14 AM Resident #5 stated he had been wearing oxygen almost daily for a couple years. Resident #5 stated the staff check his oxygen saturation a couple of times a day. Review of Resident #5 ' s Care Plan documented oxygen therapy related to shortness of breath and diagnosis of COPD. Review of Resident #5 ' s Physician Orders documented the most recent oxygen order was discontinued on 1/11/23. On 5/21/24 at 3:54 PM Staff I, Licensed Practical Nurse (LPN) 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 clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance twice weekly and/or per resident preference for 4 of 4 residents reviewed for bathing (Resident #5, #11, #12, #13). Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed the Brief Interview for Mental Status (BIMs) score of 15, indicating no cognitive impairment. The MDS revealed Resident #5 required functional status under bathing revealed Resident #5 is totally dependent on staff and needed one person's physical assistance. The MDS included diagnoses of hypertension (high blood pressure), traumatic brain injury, hemiplegia (paralysis on half of the body) and depression. The Care Plan revised 6/13/23 identified Resident #5 required assistance from one person for bathing. The Electronic Health Record (EHR) bathing record lacked documentation of completed baths from 7/1/23 to 7/10/23 and 7/12/23 to 7/17/23. The record…

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 keep all residents safe from abuse for 1 of 3 reviewed (Resident #2). Resident #2 had a diagnosis of dementia with behavioral disturbances. Around 8:00 PM, while caring for Resident #2, one of three Certified Nurse Aides (CNA)'s, Staff G, saw another CNA, Staff H, with a closed fist and then heard the hand connect with Resident #2's back. Staff G said Staff H and Resident #2 exchanged cuss words between the two. According to the CNA in training, Staff E, she didn't see Staff H hit Resident #2 but did hear him ask why she hit him. Staff G reported that she didn't intervene and was in shock after the situation. Staff G failed to report the incident to the nurse for 4-5 hours after the incident and 2 hours after Staff H went home from the night, allowing Staff H to continue working with other residents for additional 2 hours. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental…

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 adequate assessments and interventions for 2 of 2 residents reviewed (Residents #2 and #6). The facility failed to provide treatment for Resident #2's chronic sores on his legs as ordered and failed to notify the doctor when his wounds changed. The facility failed to offer to apply Resident #6's edema wear to treat his edema (swelling) of his left leg as ordered and charted the treatment as refused. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive deficit. Resident #2 rejected care every 4-6 days. Resident #2 required extensive assistance from one person for transfers, dressing, toilet use, and personal hygiene. The MDS included a diagnosis of dementia with other behavioral disturbances. The MDS listed Resident #2 as frequently incontinent of urine and bowel. The Care Plan for Resident #2, revised on 3/15/23,…

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.