Integrity Hc Of Marion

Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This failure has the potential to affect all 112 residents residing in the facility. Findings Include:On 11/21/25 at 2:19PM, R1 was alert and oriented and was asked how his meals were and if they were they served on time. R1 stated, It seems like we have a lot of reruns on the meals, but I think they try to follow the menu the best they can. R1 stated the meals are sometimes late and he wasn't sure why. When asked if the food and time the meals were served was ok, R1 stated, Well, that is debatable. On 11/21/25 at 3:30PM, V5 (Head Cook) stated there was a no call/no show for the shift so they are running way behind on everything. V5 said they usually have all the dishes from lunch done by now. V5 stated they are short staffed right now and are sometimes late with the meals.On 11/21/25 at 4:50PM, several residents were observed to be sitting in the big dining room awaiting the supper meal to be served. R4 was sitting in a recliner chair at a table in the dining room…

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 a resident was free from intimidation/verbal abuse for 1 (R11) of 3 residents reviewed for abuse in the sample of 13.Findings include:R11's admission Record documents an admission date of 10/21/25, and included diagnoses of Osteomyelitis, Type 2 Diabetes Mellitus with skin complications, Traumatic Amputation of Right Great Toe, Hyperlipidemia, Bipolar Disorder, and Hypertension.R11's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R11's cognition is intact. A facility document titled Employee Action Form with V11's (Former Dietary Aide/Cook) name on it documents her last day worked as 11/17/25. Under Employee Action/Discipline is a box for selected for Termination with a Termination Date written in as 11/18/25. The offense listed documents, Insubordination, including refusal to do job assignment. A date and time of incident is listed as 11/17/25 at 6:30pm and location listed 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 interview and record review, the facility failed to report an allegation of verbal abuse to the State Agency and local law enforcement within 24 hours for 1 (R11) of 3 residents reviewed for reporting alleged violations in the sample of 13.Findings include:R11's admission Record documents an admission date of 10/21/25, and included diagnoses of Osteomyelitis, Type 2 Diabetes Mellitus with skin complications, Traumatic Amputation of Right Great Toe, Hyperlipidemia, Bipolar Disorder, and Hypertension.R11's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R11's cognition is intact. A facility document titled Employee Action Form with V11's (Former Dietary Aide/Cook) name on it documents her last day worked as 11/17/25. Under Employee Action/Discipline is a box for selected for Termination with a Termination Date written in as 11/18/25. The offense listed documents, Insubordination, including refusal to do job assignment. A date and time 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 interviews and record review, the facility failed to complete a thorough investigation in response to an allegation of staff to resident verbal abuse for 1 (R11) of 3 residents reviewed for abuse in the sample of 13.Findings include:R11's admission Record documents an admission date of 10/21/25, and included diagnoses of Osteomyelitis, Type 2 Diabetes Mellitus with skin complications, Traumatic Amputation of Right Great Toe, Hyperlipidemia, Bipolar Disorder, and Hypertension.R11's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R11's cognition is intact. A facility document titled Employee Action Form with V11's (Former Dietary Aide/Cook) name on it documents her last day worked as 11/17/25. Under Employee Action/Discipline is a box for selected for Termination with a Termination Date written in as 11/18/25. The offense listed documents, Insubordination, including refusal to do job assignment. A date and time of incident is listed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure timely incontinence care and repositioning services were provided for 3 (R4, R5, and R10) of 5 dependent residents reviewed for Activities of Daily Living (ADL) care in the sample of 13.Findings include:1. R4's admission Record documents an admission date of 5/11/22, and included diagnoses of Fracture of part of Neck of Right Femur, Type 2 Diabetes Mellitus, Unspecified Dementia, Convulsions, Anxiety Disorder, and Cognition Communication Deficit. R4's MDS (Minimum Data Set), dated 10/7/25, documented a BIMS (Brief Interview for Mental Status) score of 3, indicating R4 has severe cognition impairment. Under Functional Abilities and Goals, the MDS documents R4 is dependent for eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer.2.…

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 interventions were developed and implemented for the prevention of pressure ulcers for 1 (R5) of 3 residents reviewed for pressure ulcers in the sample of 13.Findings include:R5's admission Record documented an admission date of 12/20/2021, and included diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified Protein-Calorie Malnutrition, Osteoporosis, Malignant Neoplasm of Upper Lobe, Right Bronchus or Lung, Hypertension, Hypothyroidism Anemia, Major Depressive Disorder, Anxiety, Drug Induced Dyskinesia, Scoliosis, and Cognitive Communication Deficit.R5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS Section GG (Functional Abilities and Goals) documented R5 is dependent on staff for rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer, toilet transfer,…

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 provide adequate supervision to prevent an elopement for 1 of 3 residents (R1) reviewed for elopement risk in the sample of 15.This past noncompliance occurred from 10/19/2025 to 10/20/25.Findings include:R1's admission record documents an admission date of 9/13/25, with the following diagnoses: unspecified intellectual disabilities, paranoid schizophrenia, anxiety, unspecified, and difficulty in walking.R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 13, indicating R1 is cognitively intact.R1's Elopement/Wandering Risk Assessment, dated 8/27/25, documents R1 is at risk for wandering and elopement.R1's Care Plan documents R1 is an elopement risk/wanderer related to impaired safety awareness, reports he is waiting for someone to come get him, frequently sits by exit doors with an initiation date of 9/15/25. Interventions listed include in part; Identify pattern of wandering.Intervene as appropriate.R1's…

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

Based on observation, interview, and record review, the facility failed to keep the dry storage free of contamination of rodents and rodent droppings. This failure has the potential to affect all 94 residents residing in the facility. Findings include:On 8/14/25 at 11:50 AM, in the dry storage room in the kitchen, there was a pile of small pieces of plaster/wood with a hole above it noted in the corner. Shelves containing food items around the outer perimeter of the room had several mouse droppings on them.On 8/14/25 at 12:04 PM, V1 (Administrator) said the pest control company had covered up 3 holes in the walls of the dry storage area they believed mice were getting in through, but was unaware the mice had chewed through one. V1 said she would have the Maintenance Director to fill the hole with steel wool and recover the hole.On 8/14/25 at 2:47 PM, V2 (Regional Clinical Director) said the facility did not have a dry storage area policy.The facility's revised May 2008 Pest Control policy documented in part . 1. This facility maintains an on-going pest control program to ensure that…

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

Based on observation, interview, and record review, the facility failed to ensure the facility was free of rodents. This failure has the potential to affect all 94 residents residing in the facility.Findings include:On 8/14/25 at 9:46 AM, R2 said she had seen a couple of mice in her room and had found a small mouse dead in her trashcan. R2 said she had seen a mouse in the room next to hers that was connected through a bathroom. R2 said she thought the mice may have been coming into her room from the room next door. R2's 5/19/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 was cognitively intact.On 8/14/25 at 9:45 AM, the room next to R2 connected by a bathroom had pieces of breakfast foods scattered around the floor and a black mouse bait box in the corner. On 8/14/25 at 10:15 AM, R3 said she had seen a mouse in the corner of her room earlier in the week. R3 said she had scared the mouse away and it ran out into the hallway. R3 said she had a box under her bed that she kept shoes in and it had a large amount of mouse…

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 residents had water available to them in their rooms for 4 of 4 (R1, R2, R6, R7) residents reviewed for hydration in the sample of 19. Findings Include: 1.R2's facility admission Record, with a print date of 08/07/2025, documents R2 was admitted to the facility on [DATE], with diagnoses that include cerebral palsy, acute kidney failure, diabetes, and hypertension.R2's MDS (Minimum Date Set), dated 07/22/2025, documents R2 has a BIMS score of 12, indicating a moderate cognitive deficit. R2's current Care Plan documents a Focus area of, (R2) has potential for nutritional complications r/t (related to) obesity and dietary restrictions secondary to therapeutic diet .(R2) is on an LCS (low concentrate sugars), regular texture diet, with thin liquids. Date Initiated: 04/18/2025. This same Focus area includes the intervention of, Provide, serve diet as ordered .On 7/31/25 at 1:53 PM, R2 was laying in his bed with the bedside table located…

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 they had a working call system for 5 of 5 residents (R1, R2, R4, R6, R7) reviewed for call lights in the sample of 19. Findings Include:1.R1's facility admission Record, with a print date of 8/4/25, documents R1 was admitted to the facility on [DATE], with diagnoses that include right femur fracture, generalized anxiety disorder, muscle weakness, and difficulty walking. R1's MDS (Minimum Data Set), dated 7/27/25, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. R1's current Care Plan documents a Focus area of, Transferring: (R1) has a self care deficit in transferring r/t (related to) recent fall with R (right) femur fx (fracture), WBAT (weight bearing as tolerated) status to RLE (right lower extremity), and deconditioning. Date Initiated: 07/23/2025. This Focus area includes the intervention of Use adaptive equipment: Standard Walker/Rolling Walker/ Quad Cane/Sliding Board/Gait…

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 call lights were within reach for 1 of 1 (R1) resident reviewed for accommodation of needs in the sample of 19. Findings Include:1.R1's facility admission Record, with a print date of 8/4/25, documents R1 was admitted to the facility on [DATE], with diagnoses that include right femur fracture, generalized anxiety disorder, muscle weakness, and difficulty walking.R1's MDS (Minimum Data Set), dated 7/27/25, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact.R1's current Care Plan documents a Focus area of, Transferring: (R1) has a self care deficit in transferring r/t (related to) recent fall with R (right) femur fx (fracture), WBAT (weight bearing as tolerated) status to RLE (right lower extremity), and deconditioning. Date Initiated: 07/23/2025. This Focus area includes the intervention of Use adaptive equipment: Standard Walker/Rolling Walker/ Quad Cane/Sliding Board/Gait belt.…

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 medications were available as ordered by the physician for 1 of 1 (R3) residents reviewed for pharmacy services in the sample of 19. Findings Include:R3's facility admission Record, with a print date of 8/4/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include sacroiliitis, surgical aftercare, diabetes, asthma, anemia, restless leg syndrome, Alzheimer's disease, and radiculopathy of lumbar region.R3's Baseline Care Plan, dated 7/30/25, documents R3 is alert with cognitive impairment. This Care Plan documents, family states resident gets confused at times. Under Pain, this Care Plan documents R3 is in pain with no pain level documented.R3's Order Summary Report documents the following physician orders were started on 7/30/25: Aricept 5 milligrams (mg) give 5 mg by mouth at bedtime, Lantus 100 unit/ml (milliliters) inject 30 units subcutaneously at bedtime for diabetes, Lyrica 100 mg give 100 mg 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.

Based on interview, record review and observation, the facility failed to protect and promote residents rights for 1 of 3 (R1) residents reviewed for resident rights in a sample of 12. Findings included: R1's admission record documented R1 was admitted to this facility on 6/18/2025, with diagnoses of sepsis due to methicillin susceptible staphylococcus aureus, infection and inflammatory reaction due to cardiac and vascular implant device and presence of cardiac pacemaker. R1's admission record documented R1 has an expected length of stay to be 21 days. R1 is alert and oriented. R1's care plan with admission date of 6/18/2025 documented R1 has a focus area of: (R1) has a functional self care performance deficit r/t (related to) recent hospital stay, weakness and deconditioning. (R1) is independent for most functional tasks. (R1) is independent for eating. (R1) is able to perform most bed mobility tasks independently. (R1) is continent of bowels and bladder. (R1) is able to ambulate with supervision. (initiation date of 6/26/2025). Care planned interventions included: Discuss with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review. the facility failed to ensure adequate staffing to meet the needs of the residents timely. This has the potential to affect all 96 residents who currently reside at the facility. Findings Include: The facility Resident Matrix dated 6/2/25 documents 96 residents currently reside at the facility. 1. R43's admission Record documented R43 was readmitted to this facility on 5/28/2024. with diagnoses of type 2 Diabetes Mellitus with neuropathy and foot ulcer, need for assistance with personal care and muscle weakness among others. R43's MDS (Minimum Data Set), dated 4/8/2025, documented R43 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicates R43 is cognitively intact. This same MDS documented R43 is dependent on staff for toileting and personal hygiene and needs moderate assistance with transferring. On 06/03/25 at 08:43 AM, R43 said, Call lights take forever to get answered. On 6/1/25, which was Sunday, I waited over an hour for call lights 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 interview, observation, and record review, the facility failed to store, handle, and sanitize food and food contact surfaces to prevent contamination. This failure has the potential to affect all 96 residents residing in the facility. Findings include: On 06/02/25 at 9:39 AM, there was a large accumulation of ice on the floor of the freezer. The accumulation of ice was over 1.5 feet by over 1 foot and over 9 inches tall. There was also ice on two boxes of food. One box had individual ice creams in it, and the ice had caused some of the ice creams to fall out of the box onto the floor. On 06/02/25 at 9:39 AM, V21 (Dietary Manager) stated they have a leak, and when there is a storm more water comes in, and they have been short staffed, and V21 has been working as a cook also, and has not had time to clean it up. On 06/02/25 at 12:00 PM, V23 (Dietary Aide) transferred glasses with gloves on, by the rim area where residents would drink from, after touching the milk carton, her shirt, the drink cart, health shakes, the ice scoop, and her face. On 06/02/25 at 12:15 PM, V38…

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, observation, and record review, the facility failed to provide food portions as directed by the dietary spreadsheet approved by the registered dietician for 4 (R17, R53, R61, and R63) of 17 residents reviewed for dining in a sample of 52. Findings include: 1.R17's admission Record documents an admission date of 02/02/22, with diagnoses including: type 2 diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction, vitamin D deficiency, dementia, major depressive disorder, muscle weakness, and peripheral vascular disease. R17's Physician Order Sheet documents an order of no added salt diet with regular texture and thin liquid consistency with directions stating whole milk three times a day for nutrition, with an ordered date of 01/30/23, and a start date of 01/30/23 and an end date of indefinite. 2. R53's admission Record documents and admission date of 12/22/23, with diagnoses including: chronic kidney disease, dementia, adult failure to thrive, anemia, Alzheimer's disease, and weakness. R53's Physician Order Sheet…

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, observation, and record review, the facility failed to serve food at a preferred palatable temperature for 4 of 17 residents (R17, R53, R61, R63) reviewed dining in a sample of 52. Findings include: On 06/02/25 at 8:30 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. The facility document titled, Diet Spreadsheet, dated day 23 Monday, documents: regular: honey glazed ham 3 oz (ounces). On 06/02/25 at 12:05 PM, V21 (Dietary Manager) took the temperature of the sliced ham in three different locations of the ham before serving the ham. The temperature of the ham was 90 degrees Fahrenheit in all three locations of the ham when the ham was temped. On 06/02/25 starting at 12:07 PM, V21 served the ham without any attempts at raising the temperature of the ham. 1. R17's admission record documents an admission date of 02/02/22. R17's physician order sheet documents an order of no added salt diet with regular texture and thin liquid…

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, observation, and record review, the facility failed to provide food in a texture according to physician orders for 4 (R10, R22, R28, and R56) of 17 residents reviewed for dining in a sample of 52. Findings include: 1. R22's admission Record documents an admission date of 02/17/22, with diagnoses including: hemiplegia and hemiparesis following cerebral infarction, arthropathic psoriasis, dementia, anemia, major depressive disorder, anxiety disorder, Alzheimer's disease, chronic pain syndrome, muscle weakness, chronic kidney disease, and restlessness and agitation. R22's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment and eating assistance required as setup or clean up assistance needed indicating helper sets up or cleans up, resident completes activity, helper assists only prior to or following the activity. R22's Order Summary Report documents an order for a regular diet with a mechanical soft…

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 answer call lights for residents needing assistance in a timely manner to promote dignity for 3 residents (R36, R43, R55) of 24 residents reviewed for dignity in the sample of 52. Findings including: 1. R43's admission record documented R43 was readmitted to this facility on 5/28/2024, with diagnoses of type 2 Diabetes Mellitus with neuropathy and foot ulcer, need for assistance with personal care, and muscle weakness, among others. R43's MDS (Minimum Data Set), dated 4/8/2025, documented R43 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicates R43 is cognitively intact. This same MDS documented R43 is dependent on staff for toileting and personal hygiene, and needs moderate assistance with transferring. On 06/03/25 at 08:43 AM, R43 said, Call lights take forever to get answered. On 6/1/25, which was Sunday, I waited over an hour for call lights to be answered. On 6/5/25 at 9:15 AM, R43 said yesterday…

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 formulate or offer to formulate an Advanced Directive for 2 of 24 residents (R57, R300) reviewed for Advanced Directives in a sample of 52. Findings included: 1. R57's admission Record documented R57 was admitted on [DATE], with diagnoses of metabolic encephalopathy, dementia, and pressure ulcer of the sacral region, among others. This same Admissions Record under the section titled Advanced directives has a blank space. R57's MDS (Minimum Data Set), dated [DATE], documented R57 with a BIMS (Brief Interview for Mental Status) score of 0 out of 15, which indicates R57 has severe cognitive impairment. R57's care plan does not include a focused area of care for R57's choice for Advanced Directives. On [DATE] at 9:00 AM, V25 (Registered Nurse) said she was the nurse responsible for R57's care that day. V25 said R57 had lived at this facility for about 5 weeks, and is dependent on staff for all activities of daily living. After V25 reviewed R57's EHR…

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 allegations of peer-to-peer abuse were reported to the Administrator timely for 1 of 1 (R37) resident reviewed for abuse in the sample of 52. Findings Include: R37's admission Record, with a print date of 6/9/25, documents R37 was admitted to the facility on [DATE], with diagnoses that include metabolic encephalopathy, schizoaffective disorder, vascular dementia, and altered mental status. R37's MDS (Minimum Data Set), dated 3/23/25, documents a BIMS (Brief Interview for Mental Status) score of 07, which indicates R37 has a severe cognitive deficit. R37's current Care Plan documents a Focus initiated 5/21/2019 of, (R37) has impaired cognitive function/impaired thought processes r/t (related to) metabolic encephalopathy and vascular dementia. She is at increased risk for communication difficulties d/t (due to) altered mental status, but she is usually able to make herself understood and usually able to understand others. R44's admission 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 interview and record review, the facility failed to provide a copy of the bed hold policy to residents or their representatives for a resident who had been hospitalized for 2 of 2 residents (R28, R88) reviewed for hospitalizations in the sample of 52. Findings include: Facility's bed hold policy notification, dated 1/2021, documents, This Bed Hold Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. 1. R28's face sheet documents an admit date of 11/18/24. Related diagnoses obtained from electronic health record (EHR) includes but are not limited to chronic obstructive pulmonary disease, unspecified dementia, need for assistance with personal care, and diverticulosis of large intestine. R28's current physician orders documented in the EHR include lorazepam oral tablet 0.5 MG - give 0.5 mg by mouth every 2 hours as needed for restlessness, diphenhydramine hcl capsule 25 MG - give 1 capsule by mouth every 6 hours as needed 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 interview and record review, the facility failed to ensure a current PASSR (Preadmission Screening and Resident Review Evaluation) 2 screening was in place for 1 of 5 (R36) residents reviewed for PASSR's in the sample of 52. Findings Include: R36's admission Record, with a print date of 6/4/25, documents R36 was admitted to the facility on [DATE], with diagnoses that include schizoaffective disorder, agoraphobia with panic disorder, insomnia, major depressive disorder, and anxiety disorder. R36's MDS (Minimum Data Set), dated 3/24/25, documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R36 is cognitively intact. R36's current Care Plan documents a Focus area of (R36) has dxs (diagnoses) of anxiety, depression, schizophrenia, and agoraphobia with panic disorder Has history of s/s (signs/symptoms of schizophrenia (increased paranoia, agitation, hallucinations, disorganized speech) although these have been controlled with medications. Date Initiated: 04/08/2024. Interventions…

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 assist resident with dietary needs for 3 residents of 17 (R10, R22, and R61) residents reviewed for dining in a sample of 52. Finding include: 1. R22's admission record documents an admission date of 02/17/22, with diagnoses including: hemiplegia and hemiparesis following cerebral infarction, arthropathic psoriasis, dementia, anemia, major depressive disorder, anxiety disorder, Alzheimer's disease, chronic pain syndrome, muscle weakness, chronic kidney disease, and restlessness and agitation. R22's Minimum Data set (MDS), dated [DATE], documents a Brief interview of mental status (BIMS) of 06, indicating severe cognitive impairment and eating assistance required as setup or clean up assistance needed indicating helper sets up or cleans up, resident completes activity, helper assists only prior to or following the activity. R22's care plan documents a focus area of: R22 has potential for nutritional problems related to anemia, vitamin…

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 medications were stored using current standards of practice for 1 of 1 resident (R68) reviewed for medication storage in the sample of 52. Findings Include: R68's admission Record, with a print date of 6/4/25, documents R68 was admitted to the facility on [DATE], with diagnoses that include alcohol dependence with withdrawal, chronic obstructive pulmonary edema, hypertension, anxiety disorder, and major depressive disorder. R68's Minimum Data Set, dated [DATE], documents a Brief Interview for Mental Status score of 15, which indicates R68 is cognitively intact. R68's current Care Plan documents a Focus area of, (R68) uses psychotropic medications r/t (related to) depression and anxiety. Date Initiated: 04/06/2023. This Focus area includes interventions of, Give anti-anxiety medications ordered by physician . There is no Focus area and/or intervention documented related to R68 self-administering medications. On 06/02/25 at 9:11 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 interview, observation, and record review, the facility failed to provide a meal for 1 of 17 residents (R12) reviewed for dining in a sample of 52. Findings include: R12's admission record documents an admission date of 04/23/25, with diagnoses including: metabolic encephalopathy, vascular dementia, sequelae of unspecified cerebrovascular disease, chronic obstructive pulmonary disease, anemia, hypo-osmolality and hyponatremia, major depressive disorder, anxiety disorder, polyneuropathy, visual disturbance, sensorineural hearing loss, osteoarthritis, scoliosis, dysphagia, and muscle weakness. R12's order summary report documents an order, dated 04/23/25 with no end date listed, and an order status of active, of regular diet, mechanical soft texture, and thin liquids consistency. R12's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 09, indicating R12 has moderate impaired cognition. On 06/03/25 at 8:17 AM, R12 was sitting in her wheelchair in 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.

Based on observation, interview, and record review, the facility failed to follow the resident's dietary preferences for 3 of 17 (R17, R54 and R63) residents reviewed for dining in a sample 52. Findings include: 1. R17's admission record documents an admission date of 02/02/22, with diagnoses including: type 2 diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction, vitamin D deficiency, dementia, major depressive disorder, muscle weakness, and peripheral vascular disease. R17's physician order sheet documents an order of no added salt diet with regular texture and thin liquid consistency with directions stating whole milk three times a day for nutrition, with an ordered date of 01/30/23 and a start date of 01/30/23, and an end date of indefinite. R17's diet card documents: notes: no apple juice at all. On 06/03/25 at 8:48 AM, R17 received her breakfast tray; the tray had apple juice and coffee on it. On 06/03/25 at 8:48 AM, R17 stated she does not like apple juice, and if she lets it sit there long enough, maybe it will turn into…

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, observation, and record review, the facility failed to provide adaptive equipment for 2 (R53 and R56) of 17 residents reviewed for dining in a sample of 52. Findings include: 1. R53's admission record documents and admission date of 12/22/23, with diagnoses including: chronic kidney disease, dementia, adult failure to thrive, anemia, Alzheimer's disease, and weakness. R53's physician order sheet documents an order, dated 12/22/23, of Regular diet, regular texture, thin liquids and utilized built up utensils, with an end date of indefinite, and a status of active. R53's care plan documents a focus area of: R53 has potential for nutritional complications relating to poor appetite and diagnosis of failure to thrive. She is on a regular texture general diet with thin liquids. R53 utilizes built up utensils with a date of 11/12/2024. On 06/02/25 at 1:01 PM, R53 received her lunch tray, and did not receive built up utensils; she received regular utensils. On 06/03/25 at 8:41 AM, R53 received her breakfast tray. R53's breakfast tray did not contain built up utensils;…

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 resident's medications were administered per facility policy for 1 (R1) of 3 residents reviewed for medication administration in the sample of 7. This past noncompliance occurred from 1/14/25 to 1/15/25. The findings include: R1's admission Record document R1 was admitted to the facility on [DATE]. The same document lists some of R1's diagnoses as nondisplaced fracture of Lateral Condyle of Right Tibia, Restless Leg Syndrome, and Fibromyalgia. R1's MDS (Minimum Data Set), dated 1/16/25, documents R1 has a BIMS (Brief Interview of Mental Status) of 15, which indicates R1 is cognitively intact. R1's Order Summary Report, dated 1/14/25, documents a Physician's orders for the following: Diphenhydramine (Benadryl) 50 mg (milligrams) Give 1 tablet every 4 hours for itching and Ropinirole HCL ER (Extended Release) 2 mg Give 1 tablet by mouth at bedtime for RLS (Restless Leg Syndrome). Untitled Facility Document noting Physician Standing orders document…

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 fall interventions were implemented for 1 (R2) of 3 residents reviewed for falls in the sample of 11. Findings Include: R2's admission Record documents R2 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, adult failure to thrive, repeated falls, weakness, diabetes, major depressive disorder, hypertension, peripheral vascular disease, difficulty walking, syncope and collapse. R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 12, which indicates R2 has a moderate cognitive deficit. R2's current Care Plan documents a Focus area of, (R2) is at risk for falls r/t (related to) Deconditioning, Gait/balance problems. Date Initiated: 02/27/2024. The interventions for this Focus area are documented as follows.Fall mats on floor at bedside while resident is in bed. Date Initiated: 05/20/2024 .Will utilize bolster cover on bed. Date Initiated:…

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 supplements and double portions were given as ordered for 6 (R49, R52, R59, R62, R67, and R74) of 20 residents reviewed for therapeutic diets in a sample of 48. The findings include: 1. R74's admission record documents R74 was admitted to the facility on [DATE]. The same document lists some of R74's diagnoses as: unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance and anxiety, repeated falls, anxiety disorder, and bipolar disorder. R74's MDS (Minimum Data Set), dated 7/15/24, notes R74 has a BIMS (Brief interview of Mental Status) of 00,which indicates R74 has severe cognitive impairment. R74's document labeled Order Summary Report notesa diet order,dated 6/6/24,for Regular, Mechanical soft texture, thin liquids consistency, fortified pudding at lunch and dinner, ice cream at lunch supper. Super cereal at breakfast, PBJ (peanut butter and jelly) BID (twice daily) between meals. Sit at assist…

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

Based on observation, interview, and record review, the facility failed to label insulin with open dates for 4 of 10 residents (R25, R62, R81, R244) reviewed for medication labeling and storage in a sample of 48. Findings include: 1. R25's face sheet documented an admission date of 9/27/21, and diagnoses including: chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, weakness, and difficulty in walking. R25's Order Summary Report documented an 11/26/22 order for insulin lispro inject per sliding scale, and a 3/28/23 order for insulin glargine inject 10 units subcutaneously at bedtime. 2. R62's face sheet documented an admission date of 1/25/24, and diagnoses including: peripheral vascular disease, major depressive disorder, type 2 diabetes mellitus, anxiety disorder, and hypertension. R62's Order Summary Report documented a 5/22/24 order for insulin lispro inject as per sliding scale. 3. R81's face sheet documented an admission date of 3/11/24, and diagnoses including: Chronic respiratory failure with hypoxia, type 2 diabetes mellitus, secondary Parkinson's…

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

Based on observation, interview, and record review, the facility failed to provide pureed diets per facility recipes for 13 (R3, R7, R19, R26, R30, R31, R40, R51, R54, R65, R84, R89, and R245) of 20 residents reviewed for dietary needs out of a sample of 48. Findings include: On 7/16/24 at 11:31 am, V6 (Dietary Manager) pureed the pasta salad. V6 added the pasta salad into the food processor and added an unmeasured amount of ice water and three tablespoons of thickening agent. V6 then added another unmeasured amount of ice water and blended the pasta salad until smooth. On 7/16/24 at 11:48 am, V6 pureed the cheeseburgers. V6 placed 8 hamburgers, 8 slices of cheese, 2 hamburger buns, an unmeasured amount of water, and an unmeasured amount of brown gravy into the food processor. V6 blended until smooth. During the 7/16/24 noon time meal service, all residents with an order for pureed diets were served the cheese burger puree, pasta salad puree, and green bean puree. On 7/19/24 at 12:56 pm, V12 (Registered Dietitian) said she expected dietary staff to follow the recipes when preparing…

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

Based on observation, interview, and record review, the facility failed to follow physicians orders for the treatment of scalp and facial wounds for one of 48 residents (R61) reviewed for quality of care in the sample of 48. Findings include: R61's Face Sheet documented an admission Date of 2/2/24, and listed diagnoses including Parkinson's Disease, Adult Failure to Thrive, and Type 2 Diabetes. R61's current Physicians Orders documented the following orders: (Trade Name) Antimicrobial external gel (Sodium Hypochlorite), apply to left face topically every night shift for wound cleansing with sodium chloride, apply hypochlorite gel and calcium alginate gauze with bordered dressing once daily. Sodium Hypochlorite external gel, apply to open area on anterior scalp topically every night shift for wound, cleanse wound with normal saline or wound cleanser, pat dry, apply sodium hypochlorite gel, calcium alginate, and dry dressing daily. Sodium Hypochlorite external gel (Sodium Hypochlorite), apply to posterior scalp topically every night shift for wound, cleanse open area to posterior…

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 provide podiatry/toenail care for a resident with Diabetes Mellitus for 1 of 4 (R1) residents reviewed for foot care in a sample of 7. Finding include: Per R1's EHR (Electronic Heath Record) R1 was admitted to this facility on 5/23/2022, with pertinent diagnoses of Peripheral Vascular Disease, Diabetes Mellitus Type 2, Acquired absence of right great toe and absence of other right foot toes. R1's care plan, with initiation date of 7/8/2022, documents R1 has the problem/focus areas of: (R1) has Diabetes Mellitus and R1 has Peripheral Vascular Disease. This same care plan documents planned interventions for R1 of: Inspect feet as scheduled for open areas, sores, pressure areas, blisters, edema or redness, Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails and if resident has thick nails, corns, calluses, refer to podiatrist. R1's EHR under the tab titled progress notes is a nurse's note, dated 11/1/2023 at 14:20…

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

Based on observation, interview, and record review, the facility failed to follow mechanically altered diet orders and special diet orders for 46 of 46 residents (R2 and R4-R48) reviewed for special diets in the sample of 48. Findings include: 1. On 11/1/23 at 12:27 PM, the noon time meal service was observed with V12 (Dietary Aide) plating the residents meal trays. The steam table contained herbed pork roast, braised cabbage, rice pilaf, a dinner roll, along with pureed herbed pork roast, braised cabbage, and rice pilaf. Dessert was premade peach cobbler. During the meal service, resident trays with meal tickets indicating low concentrated sweets were given a bowl of peach cobbler containing equal amounts to the meal trays with meal tickets indicating regular diets. Meal trays indicating mechanical soft diets were given the same herbed pork roast and rice pilaf as the meal trays with meal tickets indicating regular diets. The herbed pork roast was in pieces larger than a quarter. The pureed rice pilaf looked lumpy with individual rice grains being visible. On 11/1/23 at 1:04 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure pureed diets were prepared to correct consistency for 1 of 8 residents (R5, R7, R26, R41, R43, R62, R70 and R247) reviewed for a pureed diet in the sample of 39. The findings include: 1. R5's face sheet note R5 was admitted to the facility on [DATE]. R5's MDS (Minimum Data Set), dated 6/5/23, notes R5 has a BIMS (Brief Interview of Mental Status) of 7, which indicates R7 has severe cognitive impairment. The same MDS Section C notes R5 is on a mechanically altered diet-requires change in texture of food or liquids. R5's Physician orders, dated 7/1/23-7/31/23, notes an order for Regular Diet, Pureed texture, Nectar thick liquid consistency. 2. R247's face sheet notes R247 was admitted to the facility on [DATE]. R247's MDS, dated [DATE], notes R247 has a BIMS of 00, which indicates R247 was unable to complete the interview. The same MDS Section K notes R247 is on a mechanically altered diet-requires a change in texture of food or liquids. R247's…

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 written notice of a hospital transfer for 1 of 1 (R64) residents reviewed for transfer in the sample of 39. The Findings Include: R64's face sheet documents a date of birth of [DATE], admit date of 10/10/22, and diagnosis included: cerebral infarction, cognitive communication deficit, and altered mental status. R64's quarterly Minimum Data Assessment, dated 4/12/23, documents a Brief Interview for Mental Status of 3, indicating a severe cognitive impairment. Nursing progress notes, dated 3/10/23, document R64 was transferred out to the emergency room per resident request. On 7/13/23 at 9:30 AM, V1 (Administrator) stated they did not send a transfer form in the mail to V14 (Family Member) when R64 was sent the the emergency room on 3/10/23; they always call to alert them.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide written notice of bed hold for 1 of 1 (R64) residents reviewed for transfer in the sample of 39. The Findings Include: R64's face sheet documents a date of birth of [DATE], and diagnosis included: cerebral infarction, cognitive communication deficit, and altered mental status. R64's quarterly Minimum Data Assessment, dated 4/12/23, documents a Brief Interview for Mental Status of 3, indicating a severe cognitive impairment. Nursing progress notes, dated 3/10/23, document R64 was transferred out to the emergency room per resident request. On 7/13/23 at 9:30 AM, V1 (Administrator) stated they did not send the bed hold form in the mail to V14 (Family Member) when R64 was sent the the emergency room on 3/10/23; they always call to alert them.

Based on interview and record review, the facility failed to refer residents for a level II Pre-admission Screening and Resident Review (PASARR) assessment for 3 (R40, R44, R64) of 3 residents reviewed for PASARR screenings in a sample of 39. The Findings Include: 1. R40's face sheet documents admission to this facility on 01/12/18, with diagnoses to include anxiety, hyperglycemia, and osteoarthritis. R40's initial PASARR screening, dated 01/15/18, indicate she is appropriate for nursing services. R40's diagnosis sheet confirms she was newly diagnosed with schizophrenia on 03/04/19, major depressive disorder on 03/09/19, and severe dementia with behavioral disturbance on 10/01/22. There is no documentation in the record of R40 being referred for a PASARR II assessment. 2. R44's face sheet documents admission to this facility on 05/02/19, with a primary diagnosis of metabolic encephalopathy. R44's initial PASARR screening, dated 05/02/19, indicates she is appropriate for nursing services. R44's diagnosis sheet documents a new diagnosis of schizoaffective disorder bipolar type on…

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.