Boulder Park Terrace

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility presented a list of residents whose Medicare Part A Service had ended and were eligible to receive a SNF ABN (a document to alert of payment changes). Three Residents (R37, R41 and R56) on this list were chosen and their medical records were requested to assure proper notification had been delivered. The medical record form: SNF Beneficiary Notification Review was received for R37, R41 and R56 and each read, Was a SNF ABN, From CMS-10055 (Center for Medicare and Medicaid Services) provided to the resident? Each form had No checked and continued, If no, explain why the form was not provided. Each had a handwritten explanation which read, Change in BO (Business Office) Staff. During an interview on 6/5/25 at 12:50 PM, the Nursing Home Administrator (NHA) stated there had been a recent change in office personnel within the last month. The NHA said, The new girl in the office has been educated on the proper form to use. We have not been using the right CMS form. The form 10055 was not used. The NHA…

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 Resident #258 (R258) Review of an admission Record revealed R258 was originally admitted to the facility on [DATE]. On 6/4/25 at 9:33 AM., R258 was observed on a stretcher being wheeled out via ambulance/paramedics. On 6/4/25 at 9:35 AM, Certified Nurse Aide (CNA) C was interviewed and reported R258 was not feeling well this morning, and reported this to the nurse, and a decision was made to send R258 out to the Emergency Department (ED). Review of R258's Electronic Medical Record EMR revealed. 6/04/2025 05:32 PM Late Entry- Resident observed to be confused/difficult to arouse/complaining of feeling cold. Weak. Altered mental status Call placed to EMS (Emergency Medical Services) to transport to Hospital for evaluation NP notified/ DON (Director of Nursing) notified . Resident sent out at approx 0930. - Resident is being admitted . Nursing (documented by RN B) On 6/5/25 at 3:05 PM., RN B was interviewed and reported R258 was admitted to the hospital yesterday. When asked if a bed hold policy was given to R258,…

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 Resident #263 (R263) Review of an admission Record revealed R263 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Enterococcus bacteremia (blood stream infection). Review of a Minimum Data Set (MDS) assessment for R263 with a reference date of 5/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R263 was cognitively intact. In an interview on 6/4/25 at 2:08 PM., R263 reported staffing is so short he has to wait for assistant for long periods of time. R263 reported there are just not enough of them to help out the way they should be. R263 reported his call light took over 45 minutes the other night. In an interview on 6/4/25 at 9:35 AM., Certified Nurse Aide (CNA) C reported (staffing could be better, we struggle making sure everyone gets their showers on time or on their scheduled days. CNA C reported resident showers do get missed because the shower aide gets pulled to work the floor because of staff calling in or not showing up.…

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 facility failed to ensure drugs and biological's were stored and discarded according to professional standards and ensure a locked medication room had a functional door handle/lock for 1 of 2 medication storage rooms, and 1 of 3 medication carts reviewed for storage of medications resulting in the potential for negative side effects from outdated or ineffective drug therapy and accidental wrong medication ingestion and drug diversion. Findings include: In an interview/observation on 6/4/25 at 2:07 PM., Registered Nurse (RN) A reported the main medication room near the front door and administration offices had an issue for a while where it would slam shut very hard when leaving the room. RN A reported she thought maintenance fixed it, but clearly it is not fixed. RN A reported it would close so hard it would scare people. RN A stated they thought maintenance might have adjusted it. The medication room door did not appear to be shutting and securely closing while observing medication administration. (While…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent prior to the administration of psychotropic medications for two Residents (#16 and #36) of five residents reviewed for unnecessary medications. Findings include: Resident #16 (R16) Review of the Minimum Data Set (MDS) assessment, dated 4/16/2025, revealed R16 was admitted to the facility on [DATE] and had diagnoses including traumatic brain injury, bipolar disease, restlessness and agitation. Further review of the MDS assessment revealed R16 had moderate cognitive impairment. Review of R16's physician orders revealed an active order for Haldol (an antipsychotic medication used to stabilize mood, behaviors and thoughts) 1 milligram (mg) and 2 mg tablets by mouth daily. The order was dated 11/30/2023. Review of R16's electronic medical record (EMR) revealed no acknowledgement of informed consent (education regarding the need for the medication and the risks, benefits and alternatives) signed by R16 or their representative for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment by serving residents their meals on institutional trays in the resident dining rooms. Findings include: On 6/4/25 at approximately 8:00 AM, the breakfast meal was observed being served to residents in the main dining areas. Staff served the residents their breakfast meal with plates, cups and tableware on service trays. On 6/4/25 at 12:00 PM, the lunch trays were set up in the kitchen with items on a tray for each resident. The staff then served the meal to each resident in the dining room) without removing the items from the trays. On 6/04/25 at 4:20 PM, residents were asked about their thoughts regarding the meal service and if it was like when they were living at home. Resident #40 (R40) whose electronic medical record (EMR) contained a Brief Interview for Mental Status assessment (BIMS) dated 3/26/25 of 11 out of 15 (indicating moderate cognitive impairment) shook her head no. She said she did not eat…

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 This citation pertains to intake M00153232 Based on interview and record review, the facility failed to monitor and prevent resident to resident sexual abuse for two Residents (#14 and #40) of four residents reviewed for abuse. This deficient practice resulted in feelings of being violated, humiliation, anxiety. Findings include: Review of a facility five-day investigation summary, submitted to the State Agency (SA) on 5/23/25 at 8:54 a.m., revealed the following: On 5/19/25 (Resident #40 [R40]) groped (Resident #14 [R14's]) breast at 8:58 the incident occurred. Staff witnessed (R14) slapping her hand on (R40's) shoulder repeatedly. When asked why (R14) was doing that and they were pulled apart, (R14) stated he squished my breast. I just wanted him to stop so I was hitting him . R14 Review of the Minimum Data Set (MDS) assessment, dated 5/15/25, revealed R14 was admitted to the facility on [DATE] with active diagnoses that included Alzheimer's Disease, anxiety, and depression. R14 scored a 3 of 15 on the Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document specific behaviors, signs and symptoms of anxiety targeted by the administration of a PRN (as needed) antianxiety medication for one Resident (#36) of five residents reviewed for unnecessary medications. Findings include: Resident #36 (R36) Review of the MDS assessment, dated 1/19/2025, revealed R36 was admitted to the facility on [DATE] and had diagnoses including anxiety. Further review of the MDS assessment revealed R36 was cognitively intact. Review of R36's physician orders revealed an active order for Xanax (a controlled, antianxiety medication) 0.5 mg tablet by mouth PRN daily for Other specified anxiety disorders. The order was dated 5/28/2025 and had an end date of 6/28/2025. Review of R36's EMR, including physician progress notes for May and June 2025, no documented rationale related to the administration of the medication for more than a 14-day timeframe. Review of R36's May and June 2025 Medication Administration Records (MAR's),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure allegations of abuse were identified and reported to the State Agency (SA) for three Residents (#40, #49 and #22) of four residents reviewed for abuse. Findings include: Resident #49 (R49) Review of the Minimum Data Set (MDS) assessment, dated 4/15/2025, revealed R49 was admitted to the facility on [DATE] and had diagnoses including left ankle fracture, anxiety and schizophrenia. Further review of the MDS assessment revealed R49 was cognitively intact and had no behaviors of psychosis including hallucinations or delusions. Review of R49's electronic medical record (EMR) revealed the following progress note: 05/22/2025 12:53 PM Administrator was told a male resident was just in her room, he rolled in by wheelchair. Administrator went down to see the room and set up [sic] and apologize. Male resident had put his hand on [R49's] bed, under her cover to the left of her leg area. NP (Nurse Practitioner) in building notified, male…

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 allegations of abuse were thoroughly investigated for three Residents (#40, #49 and #22) of four residents reviewed for abuse. Findings include: Resident #49 (R49) Review of the Minimum Data Set (MDS) assessment, dated 4/15/2025, revealed R49 was admitted to the facility on [DATE] and had diagnoses including left ankle fracture, anxiety and schizophrenia. Further review of the MDS assessment revealed R49 was cognitively intact and had no behaviors of psychosis including hallucinations or delusions. Review of R49's electronic medical record (EMR) revealed the following progress note: 05/22/2025 12:53 PM Administrator was told a male resident was just in her room, he rolled in by wheelchair. Administrator went down to see the room and set up [sic] and apologize. Male resident had put his hand on [R49's] bed, under her cover to the left of her leg area. NP in building notified, male resident's guardian notified and [R49's] guardian…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure that required assessments were completed timely for four Residents (#4, #14, #42 and #44) out of 16 Residents reviewed for MDS (Minimum Data Set) assessments. Findings include: Resident #4 (R4) A review of R4's electronic medical record (EMR) revealed R4 had expired on [DATE]. The Minimum Data Set (MDS) assessment for [DATE] related to Death in Facility was noted as In process and had not been completed as of [DATE]. Resident #14 (R14) A review of R14's MDS assessment record revealed assessments were completed on [DATE], and [DATE]. The quarterly assessment after [DATE] was over 120 days old and had not been completed until [DATE] Resident #42 (R42) A review of R42's MDS assessment record revealed assessments were completed on [DATE], [DATE], and [DATE]. The quarterly assessment after [DATE] was over 120 days old and had not been completed until [DATE]. Resident #44 (R44) A review of R44's MDS assessment record revealed assessments were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Level II PASARR (Preadmission Screening and Record Review) evaluation was completed on 1 of 1 sampled resident (Resident #41) with known serious mental illness. Findings include: Resident #41 (R41) A review of R41's electronic record indicated R41 was admitted to the facility with diagnosis including bipolar disorder on 2/28/25. R41's EMR indicated a PASARR hospital exemption discharge date d 1/30/25. The PASARR hospital exemption discharge noted R41 was being admitted to facility after a hospital stay where R41 required nursing facility services for their condition they received hospital care for and likely to require less than 30 days of nursing facility services. Therefore, a PASARR II assessment would not be initiated at that time. The PASARR hospital exemption discharge also stated, if that plan changes, please notify the OBRA (Omnibus Budget Reconciliation Act) Office as soon as possible for appropriate follow-up. On 6/4/25 1:45 PM while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate baseline care planning regarding high risks focus areas for two Residents (#256 & #263) of 13 residents reviewed for baseline care planning. This deficient practice resulted in the potential for choking, complications from infections as well as overall unmet medical needs. Findings include: Resident #256 (R256) Review of an admission Record revealed R256, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Parkinson's, and dysphasia (difficulty swallowing). Review of the Minimum Data Set (MDS) 5-day admission assessment for R256, with a reference date of 5/31/25- revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated R256 was cognitively impaired. Review of R256's Care Plans revealed no Baseline Care Plan was in place for R256's focus area of difficulty swallowing and associated high risk of choking. Resident #263 (R263) Review of an admission Record revealed R263…

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 Resident #263 (R263) Review of an admission Record revealed R263 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Enterococcus bacteremia (blood stream infection). Review of a Minimum Data Set (MDS) assessment for R263 with a reference date of 5/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R263 was cognitively intact. Review of R263's medical record revealed no Comprehensive Care Plan was completed. Review of R263's physicians orders revealed: penicillin G pot (potassium) in dextrose (antibiotics) piggyback; 3 million unit/50 mL (milliliters); intravenous (via PICC [peripherally inserted central catheter] line) Other Test: Once A Day IV (intravenous) PCN (penicillin) G 24 million Units every 24 hours continuous infusion. [Diagnosis: Bacteremia] .(start date) 05/07/2025 (end date) 06/09/2025 . In an interview on 6/5/25 at 3:05 PM., RN B reported R263 receives his antibiotic medication via a PICC line. RN B reported any resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00153232 Based on interview and record review, the facility failed to ensure care plans were revised to address supervision behaviors and prevent further abuse regarding two Residents (#14 and #40) of 13 residents reviewed for revision of care plans. This deficient practice resulted in care plans which did not reflect resident needs and had the potential for continued behaviors, including resident to resident abuse. Findings include: Resident #14 (R14) Review of the Minimum Data Set (MDS) assessment, dated 5/15/25, revealed R14 was admitted to the facility on [DATE] with active diagnoses that included Alzheimer's Disease, anxiety, and depression. R14 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Resident #40 (R40) Review of the MDS assessment, dated 5/15/25, revealed R40 was admitted to the facility on [DATE]. R40 scored a 3 out of 15 on the BIMS assessment reflective of severe cognitive impairment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide behavioral health care needs to maintain the highest practicable level of physical, mental, and psychosocial well-being, for one Resident (#40) of one resident reviewed for behavioral care. This deficient practice had the potential for worsening behaviors. Resident #40 (R40) Review of the Minimum Data Set (MDS) assessment, dated 5/15/25, revealed R40 was admitted to the facility on [DATE]. R40 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Further review of the Electronic Medical Record (EMR) revealed R40 had a diagnosis of dementia. Section E Behavioral Symptoms: revealed R40 experiences physical behavioral symptoms directed toward others i.e. Hitting, kicking, pushing, scratching, grabbing, abusing others sexually every 4 to 6 days. Review of Progress Notes for R40 revealed the following pertinent entries: 3/9/25 . Resident has been inappropriate both physically and verbally with staff, resident groped this…

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 consistent follow-up and documentation of monthly medication regimen reviews (MRRs) for two Residents (#16 and #36) of five resident reviewed for MRRs. Findings include: Resident #16 (R16) Review of R16's MRRs documented in the electronic medical record (EMR) for the period of 11/1/2024 through 6/1/2025 revealed the following: 3/8/2025, 3:22 p.m. See recommendation. 6/1/2025, 11:02 p.m. See recommendation. Further review of R16's EMR revealed no documentation or pharmacy report indicating what the pharmacy recommendations were for 3/8/2025 or 6/1/2025. Resident #36 (R36) Review of 36's MRRs documented in the EMR for the period of 11/1/2025 through 6/1/2025 revealed the following: 1/19/2025, 5:07 p.m. See recommendation. 5/20/2025, 11:23 p.m. See recommendation. Further review of R36's EMR revealed no documentation or pharmacy report indicating what the pharmacy recommendations were for 1/19/2025 and 5/20/2025. On 6/5/25 at 8:43 a.m., the Director of Nursing (DON) was asked what the facility process was to ensure…

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 consistently document pain assessments and document/utilize non-pharmacological interventions prior to the administration of PRN (as needed) opioid pain medication for one Resident (#49) of five residents reviewed for unnecessary medications, resulting in the potential for adverse medication effects and/or physical dependence on controlled medications. Findings include: Resident #49 (R49) Review of the Minimum Data Set (MDS) assessment, dated 4/15/2025, revealed R49 was admitted to the facility on [DATE] and had diagnoses including left ankle fracture, anxiety and schizophrenia. Review of the MDS Section J - Health Conditions, revealed R49 almost constantly experienced pain was receiving scheduled and PRN (as needed) pain medication. Further review of the MDS assessment revealed R49 was cognitively intact and had no behaviors of psychosis including hallucinations or delusions. Review of R49's electronic medical record (EMR) revealed 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.

This deficient practice pertains to Intake MI00148356. Based on observation, interview, and record review, the facility failed to provide food to accommodate resident preferences for one Resident (#3) of 4 residents reviewed for food allergies and preferences. This deficient practice resulted in food dissatisfaction, decreased food consumption, and the potential for further weight loss. Findings include: Resident #3 (R3) Review of R3's electronic medical record (EMR) revealed initial admission to the facility on 3/1/25 with diagnoses including Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract), abnormal weight loss, and protein-calorie malnutrition. Review of R3's most recent Minimum Data Set (MDS) assessment, dated 3/9/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Review of R3's EMR revealed the following admission progress note on 3/1/25 at 11:31 PM: .Phone report received from .[local hospital] . resident [R2] admitted to [local hospital] on Monday 2/24/25 for falls at home…

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.

This deficiency pertains to intake numbers MI00145488 and MI00145642 Based on interview and record review, the facility failed to ensure sufficient numbers of staff to provide adequate care to the resident population in accordance with the facility assessment. This deficient practice resulted in the potential for unmet care needs for all 61 residents in the facility. Findings include: Resident #36 (R36) R36 was interviewed on 11/12/24 at 1:15 p.m. R36 said there was a shortage of nurses and Certified Nurse Aides (CNA) in the facility to help the residents and said call light response time was often extensive. R36 said he attends Resident Council monthly and most of the concerns conveyed by the Council members are related to poor staffing. R36 alleged staffing was especially poor in July but was also a current problem in the month of November. R36 said there were long periods of time before assistance was received from staff. The medical record of R36 was reviewed on 11/12/24. A nurse's note dated 10/25/24 at 12:43 p.m. read in part: . [R36] is requesting a shower for today however…

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 . This citation pertains to intake MI00145682. Based on interview, and record review, the facility failed to provide prompt written responses to concerns/grievances for two residents (R36 and R37) of three residents reviewed for the grievance process. This deficient practice resulted in residents becoming frustrated over feelings of being unheard due to voicing concerns multiple times and perceived lack of facility response. Findings include: Resident #36 (R36) R36 was admitted to the facility on [DATE] with a primary diagnosis of right sided weakness due to a stroke. The medical record for R36 included a Minimum Data Set (MDS) assessment dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 15 of 15 signifying cognitively intact. On 7/12/24, a complaint was received by the State Agency (SA) from R36 with several issues outlined in the document. R36 concluded So I am asking (Facility Name) nursing home to give me the answers in writing. They haven't yet! During an interview on 11/13/24 at…

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

This deficiency pertains to intake number MI00147266 Based on interview and record review, the facility failed to timely notify the state agency of a resident-to-resident altercation and failed to report the results of an investigation timely to the state agency for three Residents (R34, R35, and R36) of four residents reviewed for abuse. Findings include: Resident #34 (R34) The facility submitted a facility-reported incident (FRI) to the state agency on 6/28/24 for a witnessed resident-to-resident altercation that occurred at an unknown time on 6/26/24. The FRI reported a staff member observed Resident #35 (R35) kick the back of R34's wheelchair, and documented R35 used profanity toward R34. The FRI documented investigation started. An investigation summary was submitted to the state agency on 9/25/24, three months after the altercation occurred. The Administrator (NHA) was interviewed on 11/13/24 at 1:45 p.m. The NHA said the FRI for the altercation between R34 and R35 should have been submitted to the state agency within 24 hours of the incident, and the results of 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.

This deficiency pertains to intake number MI00147266 Based on interview and record review, the facility failed to thoroughly investigate resident-to-resident altercations for three residents (R34, R35, and R36) of four residents reviewed for abuse. Findings include: Resident #34 (R34) / Resident #35 (R35) The facility submitted a facility-reported incident (FRI) to the state agency on 6/28/24 for a witnessed resident-to-resident altercation that occurred on 6/26/24. The FRI reported the Activity Director observed R35 was using profanity and kicked the back of R34's wheelchair. The FRI documented investigation started. An investigation summary was submitted to the state agency on 9/25/24, three months after the altercation was reported. On 11/12/24 at 12:30 p.m., the Administrator (NHA) was asked for the facility investigation for the incident between R34 and R35 on 6/26/24. The Administrator provided a file folder that contained the investigation summary submitted to the state agency on 9/25/24, a photocopy of a cell phone with an undated and untimed text message, one care plan 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.

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement committee met at least once per quarter with the required committee members resulting in the potential for quality-of-care concerns for all 55 residents in the facility. Findings include: On 5/15/2024 at 3:25 p.m. a review of the available attendance documentation for the QAPI meetings with the interim-Nursing Home Administrator (NHA H) and the Director of Nursing (DON), revealed the following: Meeting held on 4/30/2024: The Medical Director or designee did not attend. Meeting held on 1/10/2024: No attendance record found. The DON reported information from the third quarter (July - September) 2023 was included with the October - December 2024 meeting on 1/10/2024. No meeting was held for the Third-quarter 2023. NHA H reported she was new and unsure where the previous NHA kept the QAPI documents. The DON called the previous NHA in the presence of this surveyor and was yet unable to locate the QAPI information needed for review. The missing attendance records 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.

Based on interview and record review, the facility failed to review resident rights with eight confidential group Residents of eight residents reviewed for awareness of their rights. This deficient practice resulted in feelings of frustration due to the lack of awareness of basic rights. Findings include: During the group meeting on 5/14/24 at 1:30 p.m., eight confidential residents reported they were unaware of their resident rights, and their rights were not reviewed at the monthly resident council meetings. Residents collectively stated, What are our rights?, and asked Surveyor to explain their rights to them. Each reported they did not understand their nursing home rights and wanted this information. The resident council president confirmed resident rights were not reviewed at their monthly meetings. Several confidential group meeting residents reported outcomes related to resident rights, including undignified communication towards them from staff, such as when they requested call light assistance, for timely care and medications. Review of the resident council meeting minutes…

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 This citation relates to Intake #MI00142921. Based on observation, interview, and record review, the facility failed to provide appropriate staffing of Certified Nursing Assistants (CNAs) to provide necessary care and services for three Residents (R18, R23, and R48) of 14 sampled residents, and six confidential interviewable Residents from the group meeting facility task. This deficient practice resulted in feelings of frustration related to delay in staff responding to call lights and the potential for adverse resident outcomes. Findings include: Review of R23's Minimum Data Set (MDS) assessment, dated 3/26/24, revealed admission to the facility on 3/19/24, with diagnoses including osteomyelitis (bone infection), diabetes, and kidney disease. R23 was dependent for toileting, required maximal assistance for transfers, and was frequently incontinent of bladder and bowel. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R23 was cognitively intact. Review of R48's 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 This citation pertains to intake MI00142921. Based on observation, interview and record review, the facility failed to ensure dignified care experiences for three Residents (R36, R20 and R39) of four residents reviewed for dignity. Findings include: R36 R36 was admitted to the facility on [DATE] and had diagnoses including stroke, aphasia (difficulty expressing and understanding speech), and hemiplegia (paralysis) and hemiparesis (weakness) affecting the right dominant side. A review of R36's Minimum Data Set (MDS) assessment, dated 3/19/2024, revealed R36 had intact long-term and short-term memory and required moderate independence [some difficulty in new situations only] with daily decision making. Further review of R36's MDS assessment revealed he required substantial/maximal assistance from staff to transfer to and from the toilet. An observation on 5/15/2024 at 12:31 p.m. revealed R36 seated in a wheelchair in his room facing the window. R36 was observed using his left arm to position his wheelchair toward…

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 properly assess mental and physical capability for self-administration of medications for one resident (R42) of one resident reviewed for self-administration of medications. Resident #42 (R42) R42's electronic medical record (EMR) revealed an admission date of 6/22/23. R11's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated R42 was cognitively intact. R42 had medical diagnoses including muscular dystrophies (muscle dysfunction), congenital stenosis and stricture of esophagus (abnormal narrowing of esophagus), dysphagia (difficulty swallowing), and acute bronchitis. R42's orders indicated ipratropium-albuterol solution for nebulization; 0.5 milligram (mg)-3 mg (2.5 mg base)/3 mL(milliliters); inhalation twice a day, creatine monohydrate powder 100% 1 scoop reconstituted in 4-8 ounces (oz) of water daily, and Metamucil Fiber 1 scoop reconstituted in 4-8 oz daily. There was no order for medications to be self-administered. On 5/14/24 at 9:41 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop comprehensive care plans for two Residents (R9 and R23) of 14 residents reviewed for care planning. This deficient practice resulted in the potential to result in unmet activity needs for R9 and additional weight loss for R23. Findings include: R23 Review of R23's Minimum Data Set (MDS) assessment, dated 3/26/24, revealed R23 was admitted to the facility on [DATE], with diagnoses including diabetes, neuropathy (nerve disease), and wound treatment. R23 required maximal assistance for transfers, dependence for toileting, and was frequently incontinent of bladder and bowel. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R23 was cognitively intact. The assessment showed R23 was 65 tall and weighed 184#. During an interview on 5/13/24 at 10:46 a.m., R23 stated she was losing weight. Review of R23's weights showed significant weight loss: 5/08/24: 181.8# 5/07/24: 184.9# 4/09/24: 178.5# 4/08/24: 184#…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, and record review, the facility failed to ensure care plans were updated and revised appropriately for two Residents (R5 and R39) out of 14 Resident care plans reviewed. This deficient practice resulted in care plans which did not reflect resident needs. Findings include: Resident #5 (R5) A review of R5's Minimum Data Set (MDS) assessment, dated 2/12/2024, revealed an admission date of 2/8/2021 and a score of 7 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating severe cognitive impairment. R5's diagnoses included repeated falls, cerebral infarction (stroke), dementia, chronic pain, diabetes, and major depressive disorder. The progress notes for R5 from 2/12/24 at 7:30 AM reported the following, This nurse called into room [ROOM NUMBER]-1 by two floor nurses stating resident had fallen in her room. Care plan was followed. Resident was found near her roommate's bed/side of the room. 2 floor nurses were already in her room and had responded to alarm sounding.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate care to prevent worsening of a catheter-associated pressure injury for one Resident (R39) of three residents review for pressure injuries. Findings include: R39 was admitted to the facility on [DATE] and had diagnoses including macular degeneration (limited field of vision), urinary retention, urinary tract infection and generalized muscle weakness. A review of R39's Minimum Data Set (MDS) assessment, dated 3/19/2024, revealed R39 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating he had moderate cognitive impairment. Further review of R39's MDS assessment revealed he had an indwelling urinary catheter and was dependent on staff for lower body dressing (ability to dress and undress below the waist, including fasteners). An observation of wound care provided by Registered Nurse (RN) D on 5/15/2024 at 10:16 a.m. revealed a ventral (underside) tear through the glans (rounded tip) 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.

Based on interview and record review the facility failed to ensure timely physician response to Medication Regimen Review (MRR) pharmacy recommendations and failed to follow the physician orders after they were written for one Resident (R5) of five residents reviewed for MRR out of a sample of 14 residents. This deficient practice had the potential to result in excessive dosage, side effects, and adverse reactions. Findings include: Resident #5 (R5) A review of R5's diagnoses included gastro-esophageal reflux disease (GERD), dementia, diabetes, major depressive disorder, and chronic kidney disease. The Minimum Data Set (MDS) assessment for R5, dated 2/12/2024, revealed an admission date of 2/8/2021. The electronic medical record revealed R5 had a current physician order for pantoprazole 20 milligrams (mg) daily for GERD. On 12/28/2023 the pharmacist performed a medication regimen review (MRR) for R5 which read in part, Please respond to the following . Resident is currently prescribed: pantoprazole 20 mg daily for GERD. For your review: State guidelines require clinical…

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

Based on observation, interview, and record review the facility failed to follow up on routine dental services for one Resident (R5) of one resident reviewed for dental services. This deficient practice resulted in R5's diet being downgraded from a regular diet to a pureed diet with a potential for weight loss and dissatisfaction with meals while waiting for her dentures to be fixed. Findings include: Resident #5 (R5) A review of R5's diagnoses included complete loss of teeth, cerebral infarction (stroke), dementia, diabetes, major depressive disorder, chronic kidney disease, and gastro-esophageal reflux disease. The Minimum Data Set (MDS) assessment for R5, dated 2/12/2024, revealed an admission date of 2/8/2021 and a score of 7 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating severe cognitive impairment. This MDS recorded a height of 5 feet 2 inches and a weight of 82 pounds. During lunch rounds in the Main dining room on 5/13/24 at 12:25 PM, R5 was observed to be eating a pureed diet (all foods blended into a baby food consistency). The medical…

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 appropriate care of an indwelling, urinary catheter for one Resident (R39) of one resident reviewed for catheter care. Findings include: R39 was admitted to the facility on [DATE] and had diagnoses including macular degeneration (limited field of vision), urinary retention, urinary tract infection and generalized muscle weakness. A review of R39's Minimum Data Set (MDS) assessment, dated 3/19/2024, revealed R39 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating he had moderate cognitive impairment. Further review of R39's MDS assessment revealed he had an indwelling urinary catheter and was dependent on staff for lower body dressing (ability to dress and undress below the waist, including fasteners), toileting hygiene, sit to stand and chair/bed-to-chair transfers. An observation on 5/13/2024 at 11:32 a.m. revealed R39 sitting in a wheelchair on the right side of his bed. Further observation…

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 store, prepare, and serve food in accordance with professional standards for food service safety as evidence by: A. Failing to ensure that refrigerated potentially hazardous foods were dated and discarded on or before the expiration date. B. Failing to properly clean areas with a potential to contaminate food during preparation. This deficient practice has the potential to result in food borne illness among any or all of the 64 residents in the facility. Findings include: During the initial tour of the kitchen on 06/06/23 at 9:15 AM, along with Certified Dietary Manager (Staff) B, the hood over the cooking equipment providing the ventilation was observed with a thick grease build up on the lip of the hood. Under the hood there were light covers and metal fittings with dust observed directly over the stove top and grill. The top of the oven directly adjacent to the stovetop and the shelving over the stovetop were observed with a thick cover of grease with dust and particles resting on the grease layer. 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 This citation pertains to intake MI00137070. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for one Resident [R34] of two residents reviewed for abuse. This deficient practice resulted in the potential for physical and psychosocial harm. Findings include: R34 was admitted to the facility on [DATE] and had diagnoses including dementia, mood disturbance and anxiety. A review of R34's Minimum Data Set [MDS] assessment, dated 4/11/2023, revealed she required extensive, two-person physical assistance with transfers, bed mobility, personal hygiene, and toileting. Further review of R34's MDS assessment revealed she scored 00 out of 15 on the Brief Interview for Mental Status [BIMS] assessment, indicating she had severe cognitive impairment. On 6/06/2023 at approximately 11:30 a.m., R34 was observed being transferred by Certified Nurse Aide [CNA] L with a sit-to-stand lift from the toilet to her wheelchair. Once seated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00137070. Based on interview and record review, the facility failed to implement their abuse policy to prevent physical abuse for one Resident (#34) of two residents reviewed for abuse. This deficient practice resulted in staff to resident physical abuse and the potential for physical and psychosocial harm. Findings include: Resident #34 [R34] was admitted to the facility on [DATE] and had diagnoses including dementia, mood disturbance and anxiety. A review of R34's Minimum Data Set [MDS] assessment, dated 4/11/2023, revealed she required extensive, two-person physical assistance with transfers, bed mobility, personal hygiene, and toileting. Further review of R34's MDS assessment revealed she scored 00 out of 15 on the Brief Interview for Mental Status [BIMS] assessment, indicating severe cognitive impairment. A review of the Incident Summary, submitted to the State Agency [SA] on 1/22/2023 at 11:15 a.m., revealed the following: [CNA E] was attempting to get [R34] to remain…

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 physician orders were followed, physician was notified of changes in condition, and documentation was completed for abnormal findings and medications withheld for one resident (Resident #54) out of 64 residents reviewed for quality of care. Findings include: Resident #54 (R54) Review of R54's face sheet revealed R54 was admitted to the facility on [DATE], with medical diagnoses including hypertensive heart and chronic kidney disease with heart failure (elevated blood pressure with kidney disease and a heart that is not pumping blood effectively), hyperlipidemia (elevated cholesterol), aortic valve stenosis (narrowing of the aortic valve), atrial fibrillation (abnormal heart rhythm), atherosclerotic heart disease (wall of the artery develops abnormalities), and transient cerebral ischemic attack (blood flow to a part of the brain stops for a brief period of time ie. stroke). On 6/7/23 at approximately 8:15 AM, an observation was…

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

Based on interview and record review, the facility failed to ensure resident safety by following planned interventions and physician orders, monitoring residents, and completing an initial fall risk assessment for a resident at high risk for falls for one resident (Residents #214) out of five residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in the potential for serious injury, and deterioration in health status. Findings include: Resident #214 (R214) Review of R214's face sheet revealed admission to the facility on 5/24/23, with diagnoses including vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), chronic pain, other specified fracture of the right pubis, subsequent encounter for fracture with routine healing, gastric ulcer with hemorrhage (bleeding), and posthemorrhagic anemia (low red blood cell count due to bleeding). The Minimum Data Set (MDS) assessment, dated 5/31/23, revealed R214 required extensive two-person assistance for transferring 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.

Based on observation, interview, and record review the facility failed to follow physician's orders to ensure safe swallow measures were in place for one Resident #47 (R47) of two residents reviewed for adaptive equipment needs. This deficient practice resulted in the potential for aspiration (inhaling a substance into the airway instead of swallowing to the stomach), leading to possible lung infection such as pneumonia. Findings include: The Electronic Medical Record (EMR) for R47 revealed an admission date of 9/24/22 with a primary diagnosis of dysphagia (difficulty swallowing) following a stroke with paralysis affecting the right dominant side as well as aphasia (difficulty speaking), moderate protein-calorie malnutrition, chronic bronchitis, and acute cough. Minimum Data Set (MDS) assessments in the EMR dated 10/1/22, 12/25/22 and 3/27/23 all indicated R47 was assessed to be coughing or choking during meals or when swallowing medications and indicated a feeding tube was in place. On 06/07/23 at approximately 11:00 AM, R47 was observed with a PEG tube (Percutaneous Endoscopic…

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.