Westborough Healthcare

Based on record review, and interview, the facility failed to post the required nurse staffing information daily. Specifically, the facility failed to: -post the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses (RN), Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN), and Certified Nurses Aides (CNA). -maintain a copy of the staffing records for 18 months as required. Findings include: During the facility survey, the surveyor observed the nurse staffing information was posted in the front lobby at the elevator on the following days: -11/12/24 -11/13/24 -11/14/24 -11/15/24 -11/18/24 The surveyor observed that the nurse staffing postings did not include the total number of hours and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LPNs, LVNs, and CNAs. During an interview on 11/18/24 at 8:03 A.M., the Director of Clinical Operations (DCO) #2 said there…

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

Based on observation, and interview, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to: -discarding food that was spoiled. -labeling/dating, storage guidelines. -maintaining the facility kitchen in a clean, sanitary, and free of dust and debris manner. Findings include: Review of the facility policy titled Food and Supply Storage Department: Dietary and Hospitality, last revised 6/2018, included the following: -Refrigerated TCS Foods (Time/Temperature Control for Safety- are perishable items that require specific time and temperature controls to limit bacterial growth and reduce risk of foodborne illness, i.e. meat, eggs, dairy products, cut fruits and vegetables) -ready to eat foods prepared on site that is held longer than 24 hours should be properly labeled and dated with the common name, the preparation date (day 1) and use by date (maximum of 7 days .) -food…

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 provide privacy and confidentiality for one Resident (#26), out of a total sample of 19 residents. Specifically, for Resident #26, the facility staff failed to ensure that personal privacy of the Resident's own body was maintained while providing personal care when he/she was observed to be naked. Findings include: Review of the facility policy titled Resident's Rights; last revised January 2024 indicated: -a dignified existence (a life where on is treated with respect, has the autonomy to make choices about their life, valued for their worth, regardless of their circumstances, allowing them to fulfil their potential and live with a sense of self-respect and self-worth). -privacy and confidentiality. Resident #26 was admitted to the facility in June 2024, with diagnoses including Schizoaffective Disorder (a combination of Schizophrenia and mood disorders), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional…

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

Based on observation, record review, and interview, the facility failed to ensure a clean, homelike environment on one unit (Spruce Unit) out of three resident care units. Specifically, the facility failed to maintain the environment in a clean and homelike manner when the source of lingering odors of stale urine and unclean body odors in the Spruce Unit hallway were not adequately addressed and resolved. Findings include: The surveyors observed the following on the Spruce Unit: -On 11/12/24 at 9:15 A.M., the hallway outside of the Day Room had a strong odor of stale urine and unclean body odor. -On 11/13/24 at 7:58 A.M., the hallway outside of the resident rooms had a strong odor of stale urine and unclean body odor. -On 11/14/24 at 9:22 A.M., the hallway outside of the Day room had a strong odor of stale urine and unclean body odor. During an interview and observation with the Maintenance Director on 11/14/24 at 10:02 A.M., the Maintenance Director said that the Spruce Unit had a noticeable smell of body odor and urine while standing in the hallway outside of the Day room. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for one Resident (#44) out of a total sample of 19 residents. Specifically, the facility failed to complete a new Level I PASARR Assessment when Resident #44 had a significat change in status with a new diagnosis of Delusional Disorders (a belief in something that is untrue) following a psychiatric hospitalization and was started on treatment with an antipsychotic medication (medication used to treat symptoms of mental illness, including delusions - false convictions about something that is not real or shared by other people). Findings include: Resident #44 was admitted to the facility in June 2021 with a diagnosis of Major Depressive Disorder (a mental disorder characterized by low…

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

Based on interview, and record review, the facility failed to ensure that a Preadmission and Resident Review Level (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness [SMI] or Developmental Disabilities [DD]) screen was completed prior to admission to the facility for two Residents (#20 and #30) out of a total sample of 19 residents. Specifically, 1. For Resident #20, the facility failed to ensure the PASRR was completed accurately to reflect a psychiatric hospitalization. 2. For Resident #30, the facility failed to ensure that a Level I screen was completed prior to admission to the facility when the Resident had active diagnoses of mental disorders. Findings include: Review of the Preadmission Screening and Resident Review (PASRR) process retrieved from: https://www.mass.gov/preadmission-screening-and-resident-review-pasrr indicates the federal- and state-required process is designed to, among other things, identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities…

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 record review, and interview, the facility failed to meet professional standards of practice pertaining to Polysomnography (sleep study) for one Resident (#10), out of a total sample of 19 Residents. Specifically, for Resident #10, the facility failed to implement a Physician's order to obtain a sleep study to diagnose Obstructive Sleep Apnea (pauses in breathing during sleep, associated with partial or complete collapse of the throat and airway) resulting in delayed interventions and treatments for the Resident based on the sleep study results. Findings include: Review of the Board of Registration in Nursing Advisory, Ruling on Nursing Practice, titled: Accepting, Verifying, Transcribing and implementing Prescriber orders. Issued 9/22/93, revised 4/11/18, indicated: -Nurse's Responsibility and Accountability: >Licensed Nurses accept, verify, transcribe, and implement orders from duly authorized Prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent…

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 two Residents (#69 and #82) out of a total sample of 19 residents were provided assistance with personal hygiene care and services. Specifically, the facility failed to ensure that: 1. Resident #69 was offered and/or provided with grooming assistance for nail care when the Resident required partial/moderate (staff does less than half the effort) assistance of staff. 2. Resident #82 was offered and/or provided grooming assistance timely for hair care, facial hair care, and personal care when the Resident required total dependence (full staff performance of an activity with no participation by resident) of staff for hygiene, bathing, and dressing. Findings include: Review of the facility policy for Activities of Daily Living (ADLs - important tasks you do on a regular basis to take care of your body and overall well-being), Supporting last revised 11/2024, indicated: -appropriate care and services will be provided for residents who…

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

Based on observation, interview, and record review, the facility failed to maintain an environment that is free of accidents and hazards for one Resident (#18) out of a total sample of 19 residents. Specifically, for Resident #18, the facility failed to: -ensure that potentially hazardous smoking materials were stored in a secure area, and not inappropriately and insecurely stored in Resident #18's bedroom when both a stationary oxygen concentrator and portable oxygen concentrator were also stored and utilized in his/her bedroom putting the Resident and other residents at risk for accidental injury when there was easy access to the smoking materials. Findings include: Review of the facility's Policy titled Smoking Policy- Residents, established 11/2017 and last reviewed 3/2024 indicate the following: This facility shall establish and maintain safe resident smoking practices. -Oxygen use is prohibited in smoking areas. -Any smoking-related concerns will be noted in the resident care plan. -Residents are not allowed to keep lighters with them. Resident #18 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide care and services according to professional standards of practice pertaining to an indwelling urinary catheter (a flexible tube inserted into the urethra to the bladder to drain urine outside of the body) for one Resident (#64) of two applicable residents, out of a total sample of 19 residents. Specifically, the facility failed to obtain Physician's orders, develop a plan of care, maintain and/or monitor Resident #64's indwelling urinary catheter. Findings include: Resident #64 was admitted to the facility in October 2023, with diagnoses including benign prostatic hypertrophy (prostate gland enlargement that can cause urination difficulty), retention of urine (condition that occurs when a person is unable to empty their bladder completely or partially of urine), and mild cognitive impairment (slight decline in mental abilities). Review of the Resident's clinical record included a Nursing Evaluation of the bladder completed 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.

Based on observation, and interview, the facility failed to ensure that the appropriate competencies and skills related to medication administration and storage were maintained by one Nurse (#1). Specifically, the facility failed to ensure that Nurse #1 did not pre-pour the residents medications and store the pre-poured medications in the bottom of the medication cart to administer at a later time. Findings include: On 11/13/24 at 4:30 P.M., during an observation of the Hickory Nursing Unit medication cart with the Nursing Supervisor, the surveyor observed the following in the bottom drawer of the medication cart: -2 cups of crushed medications with no name, date or label. -1 pre-poured liquid medication in a cup with no name, date or label. During an interview on 11/13/24 at 4:34 P.M., Nurse #1 said she had pre-poured two residents' nighttime medications and was waiting to administer the medications to the residents with their meals at supper time. Nurse #1 said that she would pre-pour the residents' nighttime medications and mix the medications in the resident's meal at supper…

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

Based on observation and interview, the facility failed to accurately and safely provide pharmaceutical services pertaining to administering and storing medications on one of three medication carts observed. Specifically, the facility failed to ensure that medications were not pre-poured in medication cups and the pre-poured medication and medication cups stored in the medication cart prior to being administered to residents. Findings include: Review of the facility policy titled, Administration Procedures for All Medications, revised August 2020 indicated: -Once removed from the package or container, unused or partial doses should be disposed of in accordance with the medication policy. -If the medication is a controlled substance, the procedure for destruction of controlled substances should be followed. Review of the facility policy titled, Storage of Medications, revised August 2020, indicated: -The provider pharmacy dispenses medications in containers that meet regulatory requirements, medications are kept in these containers. -All medications dispensed by the pharmacy are…

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

Based on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater when one Nurse (#2) of one Nurse observed during the medication pass procedure, made five errors in 35 opportunities, for a total medication error rate of 15.15%, impacting one Resident (#2) out of five residents observed, out of a total sample of 19 residents. Specifically, for Resident #2, Nurse #2 failed to: 1. Administer the correct dose of Ferrous Sulfate Elixir (Iron) as ordered. 2. Administer the correct form of Ferrous Sulfate Elixir as ordered. 3. Administer the following medications as ordered: Glycolax Powder (stool softener)/ Levetiracetam Solution (antiseizure medication)/Artificial Tears Solution (eye drops)/Ocean Spray Nasal Solution. 4. Administer the correct form of Omeprazole suspension as ordered. 5. Individually crush and administer all the medications separately. Findings include: Review of the facility policy titled Administration Procedures for All Medications, revised August 2020, indicated: -Medications will…

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 records reviewed and interviews for one of three sampled residents (Resident #2), who had a legal guardianship in place, which was updated on [DATE] to include the right to make decisions regarding Advanced Directive with an elected code status of Do Not Resuscitate (DNR, medical order which instructs healthcare providers not to do cardiopulmonary resuscitation, in the event of cardiac or respiratory arrest) the Facility failed to ensure that new physician's orders were obtained, so in the event of cardiac or respiratory arrest, staff did not attempt to resuscitate him/her. Findings include: Review of the Facility's Policy titled Resident Rights, dated 01/2024, indicated all residents would be treated with kindness, respect, and dignity. Review of the Facility's Policy titled Advanced Directives, dated 01/2024, indicated the following: -Advanced Directive is a written instruction, recognized by State law, relating to the provisions of health care when the individual is incapacitated. -Advanced…

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 records reviewed and interviews for three of seven sampled Employee Personnel Records (Certified Nurse Aide (CNA) #1, CNA #2, and Nurse #2, who were all contracted to work at the facility through a staffing agency), the Facility failed to ensure that Massachusetts Nurse Aide Registry (NAR) checks were conducted prior to their date of employment at the facility, in accordance with their Abuse Policy. Findings include: Review of the Facility's Policy and Procedure titled Abuse: Screening, dated December 2017, indicated the following: -all employees will be screened to rule out a history of abuse, neglect, or mistreating resident. This includes attempting to obtain information from previous employers and/or current employers, and checking with appropriate licensing boards and registries, and -the Nurse Aide Registry is checked prior to employment for all facility employees. Review of the Staffing Agency Agreement between the Facility and Staffing Agency #1, dated 03/15/22, indicated that the Agency hereby represents that she/he has complied with all Federal, State, and local…

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 an environment that was free of accidental hazards, for five Residents (#88, #45, #42, #70 #104 and #54) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident #88, assess for the ability to safely self-perform g-tube (gastrostomy tube- a tube placed through an opening into the stomach from the abdominal wall, made surgically for the introduction of food) care when the Resident cut off his/her g-tube with scissors while performing an unsupervised dressing change. 2. For Resident's #45, #42, #70, and #104, provide proper receptacles for the disposal of cigarette butts and proper storage of smoking materials. 3. For Resident #54, assess for the ability to self-administer medications when medications were left unsecured at the Resident's bedside and stored in the Resident's Dialysis Communication Book. Findings include: 1. Resident #88 was admitted to the facility in May 2022 with diagnoses including Gastrostomy, muscle weakness, and anxiety. Review of the facility'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, record review and interview, the facility failed to consult the Physician regarding the need to alter treatments for one Resident (#70) out of a total sample of 24 total residents. Specifically, the facility failed to consult with the Physician regarding Hospice recommendations to: -Change the size of the Resident's indwelling urinary catheter/ Foley catheter (catheter that is inserted into the bladder through the urethra to drain urine) when the catheter was leaking urine. -Change the treatment provided to care for the Resident's left buttock Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar [necrotic tissue] may be visible but does not obscure the depth of tissue loss) pressure ulcer (PU) when Therahoney (a medication used to debride non-viable tissue) was recommended for care of the Resident's PU. Findings include: Review of the facility policy, titled Hospice Services, dated April 2018, included: -Facility staff would…

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

Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for one Resident (#92) out of a total sample of 24 residents. Specifically, the facility staff failed to provide ADL assistance to Resident #92, a dependent resident who was incontinent of bowels and stool. Findings include: Review of the facility's policy, titled Activities of Daily Living (ADLs) Supporting, revised 9/2019, indicated the following: -Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), elimination (toileting). Resident #92 was admitted to the facility in May 2023 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 observation, interview and record review, the facility failed to ensure one Resident (#88) was provided with treatment and care, in accordance with professional standards of practice, relative to treatment of an upper abdominal surgical site. Specifically, the facility failed to identify and provide needed education and supplies to Resident #88, for treatment of his/her upper abdominal surgical Gastrostomy tube (G-tube) site and allowed the Resident to self-perform a treatment to the site that was not ordered by the Physician. Findings include: Review of the facility policy, titled Wound Care, dated March 2019, indicated: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. -Verify that there is a Physician's order for this procedure. -Assemble the equipment and supplies as needed. Resident #88 was admitted to the facility in May 2022 with a diagnosis of Gastrostomy Status (G-tube: tube that is placed directly into the stomach through an abdominal wall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide indwelling Foley catheter (a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system to drain urine) care, per professional standards of practice for three Residents (#9, #17 and #70) out of a total sample of 24 residents. Specifically, For Resident's #9, #17 and #70, the facility staff failed to ensure that the Residents received the right size of Foley catheter based on the Physician's orders and care plan. Findings include: Review of the facility policy, titled Foley Catheter Insertion, revised 4/2018, indicated: -Verify that there is a Physician's order for this procedure -Document the size of the Foley Catheter inserted and the amount of fluid used to inflate the balloon. Review of the facility's policy, titled Using the Care Plan, revised 4/2018 indicated: -Documentation must be consistent with the resident's care plan -Changes in the…

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

Based on record review and interview, the facility failed to maintain complete and accurate medical records for two Residents (#32 and #62) out of a total sample of 24 residents. Specifically, the facility failed to maintain accurate medical record of Resident #32 and Resident #62's advanced directives. Findings include: Review of the facility's policy titled, Advanced Directives, revised 11/2017, included: -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. -Modify the care plan as appropriate, providing all other appropriate services (i.e., those that will allow him or her to maintain the highest practicable physical, mental, and psychosocial well-being). -The resident's attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 1. Resident #32 was admitted to the facility in November 2022 with a diagnosis of Metabolic Encephalopathy…

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.