Aspen Health And Wellness

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 58 residents. The sample included 14 residents, with three residents reviewed for hospitalization and/or discharge. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 19 and his representative were provided with a bed hold policy that included the facility's per diem rate to hold a bed. The facility failed to ensure R19, and his representative was provided a written notification of transfer upon his transfer to the hospital. The facility failed to ensure that a discharge summary and a recapitulation of stay were completed upon R61's discharge from the facility. This placed R19 and R61 at risk of miscommunication between the facility and the resident's representative, and the possible missed opportunity for healthcare services. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN- elevated blood pressure), cirrhosis (chronic degenerative disease of the liver) of the liver, carcinoma…

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.

The facility identified a census of 58 residents. The sample included 14 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 34 with the discharge from hospice services. This deficient practice placed R34 at risk for unidentified care needs. Findings included: - R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (swallowing difficulty), and aphasia (a condition with disordered or absent language function). The Annual Minimum Data Set (MDS) dated 02/12/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. The Quarterly MDS dated 05/13/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the…

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

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3's Care Plan had been revised to direct staff that she was safe to self-administer her physician-ordered Voltaren gel (a pain-relieving gel). This placed R3 at risk of unsafe medication administration and adverse effects. Findings included: - R3's Electronic Medical Record (EMR) documented diagnoses of embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) of the deep veins of the right lower extremity, malignant neoplasm (an abnormal growth of cells that has the potential to invade and destroy nearby tissues or spread to distant parts of the body) of the breast, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and diabetic neuropathy (nerve damage caused by diabetes, often leading to pain, numbness, and tingling, particularly in the hands…

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.

- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal hygiene. The Significant Change Minimum Data Set (MDS) dated 08/07/24 documented R12 moderately impaired cognition. The MDS documented R12 had an indwelling catheter. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. The Quarterly MDS dated 05/06/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented that R12 had a limited range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) 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.

The facility identified a census of 58 residents. The sample included 14 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for weights to monitor for edema and fluid overload for Resident (R) 52. This deficient practice placed R52 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypotension (low blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), muscle weakness, unsteady on her feet, and the need for assistance with personal care. The admission Minimum Data Set (MDS) dated 07/12/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R52 had received antidepressant…

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.

The facility identified a census of 58 residents. The sample included 14 residents, with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R)13. This placed R13 at increased risk for pressure ulcer development. Findings Included: - R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of malnutrition, epilepsy (brain disorder characterized by repeated seizures), adult failure to thrive, cognitive communication deficit (difficulties with communication that arise from impairments in cognitive processes like attention, memory and executive functions), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), encounter 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 The facility identified a census of 58 residents. The sample included 14 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 25's Bilevel positive airway pressure (noninvasive ventilation used to assist breathing) mask, nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask and nasal cannula (a medical device that delivers supplemental oxygen or other therapeutic gases to a patient through two small, flexible tubes inserted into the nostrils) was stored in a sanitary manner. This placed R25 at an increased risk for respiratory infection and complications. Findings included: - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN - elevated blood pressure, obstructive sleep apnea (an open airway during typical breathing during sleep and a blocked airway), pulmonary edema (accumulation of extravascular fluid in the lung…

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.

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the Consulting Pharmacists (CP) identified when staff administered R52's midodrine (a medication used to treat low blood pressure) outside the physician-ordered parameters. This placed R52 at risk for unnecessary medication administration and related complications. Findings included: - R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypotension (low blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), Muscle weakness, unsteady on her feet, and the need for assistance with personal care. The admission Minimum Data Set (MDS) dated 07/12/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R52 had received…

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.

- R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypotension (low blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), muscle weakness, unsteady on her feet, and the need for assistance with personal care. The admission Minimum Data Set (MDS) dated 07/12/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R52 had received antidepressant (a class of medications used to treat mood disorders) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and hypnotic (a class of medications used to induce sleep) medication during the observation period. The Quarterly MDS dated 03/24/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R52 had received diuretic medication, antidepressant medication, 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.

- R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (swallowing difficulty), and aphasia (a condition with disordered or absent language function). The Annual Minimum Data Set (MDS) dated 02/12/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. The Quarterly MDS dated 05/13/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. R34's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/17/25, documented she had received hospice services for additional supportive care. R34's Care Plan, dated 09/12/24, documented the facility would work cooperatively with hospice team to ensure her spiritual, emotional, intellectual, physical, and social needs were met. R34's EMR under the Orders tab revealed the following physician orders: Admit to hospice services with the diagnosis of senile…

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.

The facility identified a census of 77 residents. Based on record review and interviews, the facility failed to ensure an agency nurse, Licensed Nurse (LN) G, had the required effective communication education. This deficient practice placed residents at risk for impaired communication with LN G. Findings included: - In a Grievance/Complain Report dated 02/29/24, Resident (R) 1's family stated she felt R1 was not being cared for appropriately. When she arrived on 02/28/24, R1 was lying in bed with a brief on, no incontinence pad, and a brown stain on the sheet. R1's family asked staff to change R1 and staff stated they were giving a bed bath. R1's family requested again and staff stated R1 had to wait until help came. R1's family stated she told staff they were not going to talk to her like that and that they were neglecting R1. LN G came into R1's room and pulled the privacy curtain. R1's family stated LN G loudly and rudely stated staff were done with R1's family. Upon request, the facility was unable to provide documentation that LN G completed education on effective…

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.

The facility identified a census of 77 residents. Based on record review and interviews, the facility failed to ensure an agency nurse, Licensed Nurse (LN) G, had the required resident rights education. This deficient practice placed residents at risk for impaired resident rights. Findings included: - In a Grievance/Complain Report dated 02/29/24, Resident (R) 1's family stated she felt R1 was not being cared for appropriately. When she arrived on 02/28/24, R1 was lying in bed with a brief on, no incontinence pad, and a brown stain on the sheet. R1's family asked staff to change R1 and staff stated they were giving a bed bath. R1's family requested again and staff stated R1 had to wait until help came. R1's family stated she told staff they were not going to talk to her like that and that they were neglecting R1. LN G came into R1's room and pulled the privacy curtain. R1's family stated LN G loudly and rudely stated staff were done with R1's family. Upon request, the facility was unable to provide documentation that LN G completed education on resident rights before she started…

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.

The facility had a census of 75 residents. The sample included 18 residents. Based on record review and interview the facility failed to ensure five of five nurse aides, reviewed for regular in-service education, completed an annual performance review. This placed the residents at risk for unskilled care. Findings included: - Review of Certified Nurse Aide (CNA) M, CNA N, CNA P, CNA Q, and Certified Medication Aide (CMA) R's in-service records lacked evidence of an annual performance review. On 10/19/23 at 09:19 AM, Administrative Nurse D verified the lack of documentation indicating the above staff received an annual performance review. Upon request the facility did not provide a policy regarding CNA/CMA annual performance review. The facility failed to ensure CNA M, CNA N, CNA P, CNA Q, and CMA R completed an annual performance review. This placed the residents at risk for unskilled care.

The facility had a census of 75 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services PBJ Staffing Data Report CASPER Report 1705D FY Quarter 3 2023 (April 1 - June 30) documented the facility failed to report their PBJ data for Quarter 3 2023. On 10/17/23 at 02:42 PM, Administrative Staff A verified the facility had not reported the PBJ for Quarter 3 2023 and stated they had a payroll company who was suppose to send PBJ, but they failed to report it. Administrative Staff A stated PBJ should be sent to CMS quarterly and he would be reporting it from now on. The facility's Electronic Staffing Data Submission-Payroll-Based Journal (PBJ) policy, revised 04/01/23, documented staffing and census data would be collected quarterly and was required to be timely…

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.

The facility had a census of 75 residents. The sample included 18 residents. Based on record review and interview, the facility failed to ensure the required committee members attended the Quality Assurance Performance Improvement (QAPI) Committee quarterly meetings. This failure placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 10/19/23 at 09:40 AM, the facility's Quality Assurance Performance Improvement (QAPI) meeting attendance sheets lacked signature the infection preventionist (IP) attended the meetings. On 10/19/23 at 09:50 AM, Administrative Staff A verified the quarterly sign in sheets lacked an infection preventionist signature and stated the facility did not have a designated IP. The facility's QAPI Plan, revised 5/31/23, documented the QAPI committee provides the backbone and structure for QAPI. This group includes the executive leadership team including Administrator, Director of Nursing Services, Medical Director, consulting pharmacist, infection control preventionist, plus 3 additional staff members. The…

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

- On 10/17/23 at 08:35 AM, observation revealed Licensed Nurse (LN) H performed wound care for Resident (R) 5. He placed wound care items on a clean field on the bedside table. LN H provided urine incontinence care for R5 and after placing a new brief on R5, he changed his gloves without washing his hands. The pressure wound to R5's coccyx (triangular area at the base of the spine) was without a dressing; LN H cleansed the wound and, without washing hands or changing gloves, applied Skin-prep (liquid skin protectant), Santyl (a prescription enzyme used to help break up and remove dead skin and tissue of a wound), a collagen (protein derived wound treatment used to promote wound healing) patch, then applied a bordered foam dressing. On 10/18/23 at 09:24 AM, LN H verified he should have washed his hands between removing the soiled dressing and before applying the clean wound dressings. On 10/18/23 at 09:30 AM, Administrative Nurse D verified she expected staff to wash their hands after handling soiled items. The facility's Dressings, Dry/Clean policy, dated 2013, directed staff 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.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, interview and record review, the facility failed to employ a designated Infection Preventionist (IP) as required. This placed the residents in the facility at increased risk for infection and related complications. Findings included: - On 10/17/23 at 03:07PM, Administrative Staff A verified the facility did not employ an IP. The facility's Infection Preventionist policy, dated 09/2023, stated the infection preventionist is responsible for coordinating, implementing and updating of the infection prevention and control program. Monitors changes in infection prevention and control guidelines and regulations to ensure that policies, practices, and protocols remain current and aid in preventing and controlling the spread of infections. A nurse must of earned a certificate for specialized training in infection control, and work at least part time in the facility. The facility failed to employ an IP as required placing the residents who reside in the facility at increased risk for infection…

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.

The facility had a census of 75 residents. Based on record review and interview, the facility failed to ensure three of five Certified Nurse Aides (CNAs) completed their required 12-hour annual in-services. This placed the residents at risk for receiving unskilled care. Findings included: - On 10/22/23 at 8:00 AM, review of CNA M, CNA N, and Certified Medication Aide (CMA) R annual in-service hours lacked evidence the staff had the required 12 hours of in-service training. On 10/19/23 at 09:19, Administrative Nurse D verified the facility lacked documentation the above staff completed their required 12-hour in-services. The Facility Assessment Tool, revised 09/15/23, documented staff would be provided education and training by multiple means which included online education monthly and as needed staff in-services. The tool documented staff would receive education upon hire and reviewed at least annually. The facility's In-Service Training, Nurse Aide Policy, revised August 2022, documented the facility would complete a performance review of nurse aides every 12 months. Annual…

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.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, and interview the facility failed to maintain a clean, comfortable, home like environment when the lights in the dining room were nonfunctioning, the light fixtures contained dead insects, and the dining chairs were stained and had food particles. This placed the residents at risk for decreased comfort and impaired psychosocial wellbeing. Findings included: - On 10/16/23 at 11:59 AM, observation in the main dining room revealed the following: The fluorescent light, approximately three feet (ft) long by 18 inches wide, had nonfunctioning bulbs, on the ceiling above the dining room door where the STOP sign was posted. Two ceiling fluorescent light fixtures, close to the kitchen entrance. had nonfunctioning light bulbs. On 10/16/23 at 12:00PM, observation of the main dining room revealed the following: The sink countertop edge lacked a piece of laminate trim approximately two feet wide by 4 inches wide, showing the rough wood. The countertop had another piece of laminated trim missing in…

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.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to discuss with the resident council how to file a grievance regarding their care and treatment in the facility. This deficient practice placed the residents in the facility at risk for unresolved resident concerns and decreased quality of life. Findings included: - On 10/16/23 at 11:45AM, during observation in the main dining room, 34 residents sat in wheelchairs or dining chairs at the tables. Further observation revealed at 12:40PM, residents continued to sit in the dining room and no noon meal had been served yet. On 10/16/23 at 11:57AM, observation at the rehab dining room revealed no hot meal cart had been delivered for the rehab dining room or room trays. At 12:00PM, dietary staff delivered the food cart to the hall beside the rehab dining room and left it. At 12:24 PM, observation revealed a Certified Nurse Aide (CNA) opened the meal cart and served meals in the rehab dining room. On 10/17/23 at 02:00PM, during private…

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.

The facility had a census of 75 residents. Based on observation, interview, and record review the facility failed to label insulin (hormone that lowers the level of glucose in the blood) when opened and dispose of expired medications in a timely manner. This deficient practice placed residents of the facility at risk to receive expired or ineffective medications. Findings included: - On 10/16/23 at 11:40 AM, observation revealed the southwest nurse's medication cart contained the following medications: Naproxen (pain reliever), 220 milligram (mg) a partial bottle, with an expiration date of 09/23. Insulin glargine (long acting insulin) opened 09/12/23 (33 days ago). Insulin glargine not dated when opened. Nicotine gum, 2 mg, expired 07/23/20. On 10/16/23 at 11:45 AM, Licensed Nurse (LN) E verified the expired medications should have been disposed of and staff were to date insulins when opened. The facility's Storage of Medications policy, dated 04/01/23, stated discontinued, outdated, or deteriorated medications will be destroyed according to the facility policy. Multi dose vials…

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.

The facility had a census of 75 residents. Based on observation, interview, and record review the facility failed to store foods and monitor refrigeration temperatures for the resident food storage in the nourishment rooms in accord with professional standards for food safety. This deficient practice placed the residents who received food from or stored their food in the nourishment refrigerators on two of two resident halls at risk for food borne illness. Findings included: - On 10/18/23 at 02:58 PM, observation revealed the nourishment room on the west hall had a refrigerator with a temperature of 39 degrees Fahrenheit (F). Inside the refrigerator was one bag of frozen food, unlabeled or dated; one partially eaten, unlabeled, pint of ice cream; one pizza box, not dated; two 32-ounce undated bottles of prune juice; one-half bottle of cherry soda, unlabeled or dated; one McDonalds bag with food dated 10/15, and one container of chicken rice soup, undated. On 10/18/23 at 03:35 PM, observation of the nourishment refrigerator on the east hall revealed the refrigerator temperature of 45…

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.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to provide adequate lighting in the main dining room. This placed the residents at risk for impaired quality of life. Findings Included: - On 10/16/23 at 11:59 AM, observation in the main dining room revealed the following: The fluorescent light, approximately three feet (ft) long by 18 inches wide, had nonfunctioning bulbs, on the ceiling above the dining room door where the STOP sign was posted. Two ceiling fluorescent light fixtures, close to the kitchen entrance. had nonfunctioning light bulbs. On 10/18/23 at 10:15 AM, Maintenance Staff (MS) U verified the above findings and stated he became employed with the facility in August 2023 and he was trying to catch up with work orders but was unaware of the light fixture bulbs being burned out or needing cleaned. MS U stated staff were to leave a work order for him on the facility maintenance computer program if they had any environmental issues, and he tried to make rounds every day 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.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation and record review the facility failed to provide a safe and sanitary environment, when six fluorescent ceiling light fixtures had numerous bugs, the sink counter top edge had missing pieces of laminate in the main dining room, and chairs in the rehabilitation dining room had stains and food particles three days of the onsite survey. This placed the residents at risk for decreased quality of care and life. Findings included: - On 10/16/23 at 12:00PM, observation of the main dining room revealed the following: The sink countertop edge lacked a piece of laminate trim approximately two feet wide by 4 inches wide, showing the rough wood. The countertop had another piece of laminated trim missing in the right corner approximately four inches long by two inches wide. On 10/016/23 at 12:00 PM six fluorescent ceiling light fixtures throughout the dining room had numerous dead bugs in them. On 10/16/23 at 12:24 PM, observation revealed five of the six dining chairs in the rehab dining room had…

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 The facility had a census of 75 residents. The sample included 18 residents with one reviewed for hospitalization. Based on observation, interview, and record review the facility failed to notify the State Long Term Care Ombudsman (resident advocate) of Resident (R)26's discharges to a hospital in July 2023 and in September 2023. This deficient practice placed R26 at risk for decreased oversight of transfers. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), end stage renal disease requiring dialysis (ESRD-a terminal disease of the kidneys), and heart disease. R26's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R26 required supervision for hygiene, limited staff assistance for eating, and extensive staff assistance for bed mobility, toileting,…

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 The facility had a census of 75 residents. The sample included 18 residents with one reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide a Bed Hold Notice to Resident (R) 26 upon discharge to a hospital in July 2023 and in September 2023. This deficient practice placed R26 at risk of making uninformed decisions regarding her care. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), end stage renal disease requiring dialysis (ESRD-a terminal disease of the kidneys), and heart disease. R26's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R26 required supervision for hygiene, limited staff assistance for eating, and extensive staff assistance for bed mobility, toileting, mobility. The MDS…

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 The facility had a census of 75 residents. The sample included 18 residents with one reviewed for smoking safety. Based on observation, interview, and record review the facility failed to develop a baseline care plan to include Resident (R) 127's smoking. This deficient practice placed R127 at risk for impaired safety due to uncommunicated care needs. Findings included: - R127's Electronic Medical Record (EMR) documented diagnoses of a fracture of left lower leg, schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and orthostatic hypotension (blood pressure dropping with change of position). The Minimum Data Set (MDS), dated [DATE], was in progress. R127's baseline Care Plan dated 10/06/23 lacked information regarding R127's smoking. R127's EMR lacked evidence the facility assessed the resident's ability to safely smoke and lacked determination if the resident required supervision while smoking. On 10/17/23 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 The facility had a census of 75 residents. The sample included 18 residents with one reviewed for smoking safety. Based on observation, interview, and record review the facility failed to assess Resident (R) 127 for safety while smoking. This deficient practice placed R127 at risk for accidents while smoking. Findings included: - R127's Electronic Medical Record (EMR) documented diagnoses of a fracture of left lower leg, schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and orthostatic hypotension (blood pressure dropping with change of position). The Minimum Data Set (MDS), dated [DATE], was in progress. R127's baseline Care Plan dated 10/06/23 lacked information regarding R127 smoking. R127's EMR lacked evidence the facility assessed the resident's ability to safely smoke and lacked determination if the resident required supervision while smoking. On 10/17/23 at 10:30 AM, observation revealed R127 outside 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 75 residents. The sample included 18 residents with one reviewed for hydration. Based on observation, interview, and record review the facility failed to monitor fluid intake for Resident (R) 41, as ordered by the physician. This deficient practice placed R41 at risk for fluid overload. Findings included: - R41's Electronic Medical Record documented diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), fluid overload, heart transplant status, end stage renal disease (ESRD-a terminal disease of the kidneys) with dependence on renal dialysis (procedure where impurities or wastes were removed from the blood) and cognitive communication deficit. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R41 required supervision for eating, hygiene, limited staff assistance for bed mobility, and extensive…

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 The facility had a census of 75 residents. The sample included 18 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to follow the consultant pharmacist's recommendation and obtain a specific approved indication for the use of Seroquel (antipsychotic medication used to treat psychosis and other mental emotional conditions). This deficient practice placed Resident (R)60 at risk for inappropriate use of antipsychotic medication. Findings included: - R60's Electronic Medical Record documented diagnoses of encephalopathy (disease in which the functioning of the brain is affected by some agent or condition), pervasive developmental disorder (condition resulting from delayed mental or physical development), cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), and dementia (progressive mental disorder characterized by failing memory,…

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 The facility had a census of 75 residents. The sample included 18 residents with one reviewed for psychotropic drug use. Based on observation, interview, and record review the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)60, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R60's Electronic Medical Record documented diagnoses of encephalopathy (disease in which the functioning of the brain is affected by some agent or condition), pervasive developmental…

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 DEFICIENCY TEMPLATE F 600 The facility identified a census of seventy-six residents. The sample included six residents. Based on record review, observation, and interview the facility failed to ensure Resident (R)1 was free from avoidable accidents when a staff member performed an unsafe transfer of R1. This resulted in a skin tear which placed R1 at increased risk for pain, infection or other complications. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of rheumatoid arthritis, (a long-term autoimmune disorder resulting in warm, swollen, and painful joints; Pain and stiffness often worse following rest); chronic pain syndrome, (persistent or intermittent pain that last for more than three months); chronic kidney disease, (damaged kidneys resulting in an inability to filter blood the way they should); and cardiomegaly (an enlarged heart, caused by damage to the heart muscle, a condition that makes the heart pump harder than usual). The Medicare 5- day…

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 - R18's Physician's Order Sheet, dated 11/23/21, recorded the diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R18's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R18 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded she required extensive staff assistance with personal hygiene and bathing. The Activities of Daily Living (ADL) Care Plan, dated 11/04/21, directed R18 required one staff to provide the resident assistance with bathing two times a week. R18's Bathing Report and bath sheets documented the resident received a shower/bath on Wednesday evening shift and Saturday day shift. The November Bathing Report documented the resident received a shower/bath on the following days: 11/06/21 11/09/21 11/10/21 11/13/21 11/27/21 (no shower/bath for 13 days) The…

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

The facility had a census of 71 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 20, R14, R66, R44, R25, R27, and R56s insulin (hormone which allows cells throughout the body to uptake glucose) pens and vial with the date opened and expiration date, and discard expired stock medications on two of four medication carts. This placed these residents at risk for ineffective medications. Findings included: - On 01/24/22 at 07:30 AM, observation of the [NAME] medication cart, revealed one bottle of senna plus (laxative), 100 count tablets, expired 11/21, and acetaminophen (pain reliever), 16 fluid ounces, expired 11/21. On 01/24/22 at 08:00 AM, observation of the East medication cart, revealed the following: R20's Levemir (a long acting insulin that can work for around 24 hours or longer) flex pen lacked a date opened, and date of expiration. R14's Lantus (long acting insulin) flex pen lacked a date opened, and date of expiration. R66's Glargine (long acting insulin) flex pen lacked a date opened,…

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.

The facility had a census of 71 residents. The sample included 18 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide two sampled residents, Resident (R) 9, and R44 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form 10055. This placed the residents at risk to make uninformed decisions about their skilled services. Findings included: - The Medicare Form 10055 informed the beneficiary that Medicare may not pay for skilled therapy services and provided a cost estimate for continued services. It explained: (1) if Medicare does not pay, the resident would be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, would be responsible for payment for services, or (3) does not want the listed services. A provider must issue advance written notice to enrollees before termination of services in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient…

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 The facility had a census of 71 residents. The sample included 18 residents with three reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide a low air loss (LAL) mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) as ordered by the physician for one of three sampled residents, Resident (R) 61. This placed R61 at risk to worsen her current pressure ulcer or develop more skin issues. Findings included: - The Physician Order Sheet, dated 01/02/22, recorded R61 had diagnoses of chronic pain, cerebrovascular accident (CVA) (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), and hemiplegia (paralysis of one side of the body). The admission Minimum Data Set (MDS), dated [DATE], recorded R61 had a Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired cognition). The MDS recorded R61 required extensive staff assistance with transfers,…

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 The facility had a census of 71 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to obtain respiratory assessments prior to and after the development of COVID-19 (a highly contagious respiratory condition) for Resident (R)37, placing the resident at risk for delayed identification and treatment for a decline in condition. Findings Included: - R37's Physician Order Sheet (POS), dated 10/05/21, documented diagnoses of rhabdomyolysis (a breakdown of muscle tissue breakdown resulting in the release of a protein into the blood that can damage the kidneys), chronic pancreatitis (inflammation of organ that helps digestion and regulates blood sugar), heart failure, atrial fibrillation (rapid, irregular heart beat ), cardiomyopathy (disease of heart muscle), dehydration, and disorder of the kidney. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had moderately impaired cognition, required supervision and limited assistance 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 The facility had a census of 71 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to obtain and administer blood pressure medication for one of five residents reviewed for medication use, Resident (R) 55, placing the resident at risk for elevated blood pressure and/or chest pain. Findings included: - R55's Physician Order Sheet (POS), dated 12/23/21, documented diagnoses of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm ([tumor] of lung, bladder and right ureter (the duct by which urine is passed from the kidney to the bladder), chronic obstruction pulmonary disease (COPD) (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), gastroenteritis (inflammation of the stomach lining), dehydration and hypertension (elevated blood pressure). The admission Minimum Data Set (MDS),…

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 The facility had a census of 71 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, failed to complete a pharmacist recommended GDR (gradual dose reduction) for psychotropic medications (medications that affect a person's mental state) for Resident (R) 2, and ensure a stop date or rationale for extended use for PRN (as needed) psychotropic (medications that affect a person's mental state) medication for R18. This placed R2 and R18 at risk to receive unnecessary psychotropic medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 01/05/22, recorded R2 had diagnoses of obsessive-compulsive disorder (OCD) (unreasonable thoughts and fears that lead to irrational repetitive behaviors), post-traumatic stress disorder (PTSD) (condition triggered by intense emotional and physical events/memories), depression (emotional state characterized by exaggerated feelings of sadness), 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 The facility had a census of 71 residents. The sample included 18 residents with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 6. This placed R6 at risk for inappropriate end of life cares. Findings included : - R6's Physician Order Sheet, dated 11/03/21, documented diagnoses of hypertensive heart disease with heart failure, kidney disease stage 3 (longstanding disease of the kidneys leading to kidney failure), arteriosclerotic heart disease (a thickening and hardening of the walls of the coronary arteries) and pancytopenia (a combination of three different blood disorders). R6's Significant Change Minimum…

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 The facility had a census of 71 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure urinary catheter tubing did not touch the floor for one sampled resident, Resident (R) 2. This placed R2 at risk for urinary tract infections (UTI). Findings included: - The Physician Order Sheet, dated 01/05/22, recorded R2 had diagnoses of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), history of UTI, chronic pain, and chronic obstructive pulmonary disease (COPD) (progressive and irreversible condition characterized by diminished lung capacity and difficulty breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R2 had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact) with verbal behaviors and rejection of cares. The MDS recorded R2 required limited staff assistance with transfers, dressing, toileting, personal hygiene, and had a urinary catheter. The Urinary…

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