Mission Point Nursing & Physical Rehabilitation Ce

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nephrostomy tube [surgically implanted catheter into the kidney to drain urine] drainage bags were positioned correctly for dependent drainage for one [R25] of one resident reviewed for nephrostomy tubes. Findings include:On 3/30/25 at 9:34 AM, R25 was observed lying in bed. A drainage bag was lying on an overbed tray table positioned above the height of the bed on R25's right side. A second drainage bag was lying on a pillow propped against the wall on R25's left side, positioned above the height of R25 lying in bed. Both bags and tubing did not appear to have drainage fluid. R25 was asked what the drainage bags were connected to. R25 explained they were connected to his back. When asked if they were nephrostomy tubes in his kidneys, R25 agreed.On 3/30/26 at 12:35 PM, R25 was observed lying in bed. The nephrostomy tube drainage bags were still positioned above the level of R25's kidneys with no drainage fluid in bags or…

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: 2582047. Based on interviews and record reviews the facility failed to identify a substance use disorder (sud) -alcohol, and failed to implement a care plan/interventions for the sud, for one (R302) of one resident reviewed for elopements, resulting in R302 having left the facility without the knowledge of staff. Findings include: A review of the medical record revealed R302 was admitted to the facility on [DATE] with a primary admitting diagnosis of alcohol dependence with withdrawal and was documented to have intact cognition. Further review of the medical record revealed no plan of care or implemented care plan for R302's primary diagnosis of alcohol dependence or withdrawal. A review of the medical record revealed no interventions implemented to ensure the safety of the resident. On 7/25/25 R302 was reported to the State Agency (SA) to have eloped from the facility. On 8/14/25 at 11:55 AM, a telephone interview was conducted with RN D. RN D was asked about being the assigned…

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: 2583159. Based on interview and record reviews, the facility failed to protect the resident's right to be free from mistreatment by a staff member for one resident (R303) of two residents reviewed for neglect/abuse. Findings include:A review of a Incident Summary submitted by the facility to the State Agency (SA) documented in part . A Nursing Manager reported to this Administrator that an allegation of staff abuse against (R303's name). was brought to his attention at 11:30am on 7/30/2025. The allegation was made by a Certified Nurse's Aide (CNA- CNA J) who informed the nurse manager that another CNA (CNA I) held her hand over the resident's mouth because the resident was yelling. The alleged Perpetrator was suspended immediately pending a facility investigation. (Police department name) was contacted and an officer arrived at the facility to investigate the report.A review of the medical record revealed R303 was admitted to the facility on [DATE] with diagnoses that included:…

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: 2582047. Based on interviews and record reviews the facility failed to complete a thorough investigation for an elopement and failed to submit accurate details to the State Agency (SA) regarding the elopement incident for one (R302) of one resident reviewed for an elopement. Findings include: Review of an Incident Summary submitted to the SA documented in part . At approximately 9:45pm on Friday 7/25/2025, the Administrator was notified by a facility nurse that a nearby neighbor of the facility contacted her via phone and told her that a resident had approached their house and was asking for a ride. This nurse reported that she and a Certified Nurses Aide went outside the building, found the resident and returned him safely to his room. The resident was in no physical distress.Review of an Investigation Summary documented in part . Time of Occurrence: Approximately 7:35 pm. At 9:15pm, on the day of the incident (Registered Nurse - RN C) was notified by a Certified Nurses Aide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure all admission orders were reported and reconciled with the Physician for one (R302) of one resident reviewed for an elopement. Findings include: A review of the medical record revealed R302 was admitted to the facility on [DATE] with a primary admitting diagnosis of alcohol dependence with withdrawal and was documented to have intact cognition. A review of R302's hospital discharge medications revealed the following:Lorazepam tablet sliding scale. If CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) is 0-7: No Benzodiazepine dose indicated. 1 mg (milligram) if CIWA-AR Mild - MOD 8 -15. 2 mg if CIWA - AR Mild - MOD 16-67. Greater than 35, Notify Provider. PO (by mouth), every 2 hours PRN (as needed) for Per CIWA Scale. If CIWA-Ar is 0-7: No Benzodiazepine dose indicated. If CIWA-Ar is 8-15, give 1mg then reassess 2hrs after dose given. If CIWA-Ar >15, give 2mg then reassess 1 hr after dose given (Maximum dose 12mg/day). If score >…

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: 2570372.Based on interview and record reviews the facility failed to accurately identify a pressure wound, accurately documented the worsening and correct staging of a coccyx wound for one (R301) of one resident reviewed for pressure wounds. Findings include:Based on interview and record reviews the facility failed to accurately identify a pressure wound, accurately documented the worsening and correct staging of a coccyx wound for one (R301) of one resident reviewed for pressure wounds. Findings include:A review of a complaint submitted to the State Agency (SA) documented concerns regarding the accurate assessment and description of the resident's pressure wound. A review of the medical record revealed R301 was admitted to the facility on [DATE] with a primary diagnosis of dementia and required staff assistance with all Activities of Daily Living (ADLs). A Nursing note dated 6/25/25 at 3:55 PM, documented in part . This writer was informed by resident's aide that resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2570372.Based on interview and record reviews the facility staff failed to follow the recommendation of the psych nurse practitioner (NP) and failed to identify a change of condition (urinary tract infection - uti) as the cause of a mental status/behavioral changes for one (R301) of two residents' reviewed for neglect/abuse. Findings include:A review of the medical record revealed R301 was admitted to the facility on [DATE] with a primary diagnosis of dementia and required staff assistance with all Activities of Daily Living (ADLs). A Social Service Progress Note dated 6/26/25 at 8:03 AM, recapped the recommendations from a psych consultation which documented the following . Seen 6/25/25 by (psych clinician name), NP (nurse practitioner) with psych services. Consult states the following. Patient presents with increased anxiety, agitation, and aggression. Emphasis should be placed on ruling out underlying medical or environmental contributors. Patient has a known and established…

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: 2570372.Based on interview and record reviews the facility failed to identify, follow up and follow the facility policy on weight loss for one (R301) of one resident reviewed for weight loss. Findings include: A review of the medical record revealed R301 was admitted to the facility on [DATE] with a primary diagnosis of dementia and required staff assistance with all Activities of Daily Living (ADLs). A review of the resident Weight Summary documented the following: 7/3/25 at 1:25 PM- 134.4 lbs (pounds)6/5/25 at 3:04 PM- 150.8 lbs This indicates a -10.88 loss in less than a month. There was no recorded re-weight to confirm the weight loss documented. A record review of the Electronic Medical Record (EMR) and Nutrition assessments/notes were all reviewed, and none identified the clarification of the 7/3/25 recorded weight, notification to the dietician/physician, monitoring, interventions or modifications to the resident's nutrition plan of care. A review of the facility policy…

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 implement an effective plan of action to correct identified quality deficiencies related to controlled substances (medications regulated by the government due to having a high risk of abuse and/or addiction), resulting in the continuation of deficient practices related to having an effective process to accurately account for all controlled substances for six (R704, R705, R706, R707, R709, and R710) of seven residents reviewed. This had the potential to affect all residents who resided in the facility who were prescribed controlled substances. Findings include: On 8/12/25, a revisit survey was conducted to determine compliance with deficiencies identified during the facility's recertification survey completed on 7/8/25According to a CMS (Center for Medicare and Medicaid) 2567 form dated 7/8/25, the facility was found to be noncompliant with regulatory requirements related to pharmacy services/controlled substances, specifically the failed to ensure appropriate documentation of administration and accountability…

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 #s MI00150458 and MI00152210. Based on interview and record review, the facility failed to ensure appropriate documentation of administration and accountability of controlled substances for one (R704), of four residents reviewed for medication administration. Findings include: Review of complaints reported to the State Agency included allegations that residents were not receiving their medication as ordered, and concerns with controlled substances. Review of the clinical record revealed R704 was admitted into the facility on 5/1/20, readmitted on [DATE] and signed onto hospice on 5/5/25. Diagnoses included: fibromyalgia, cerebral atherosclerosis, and unspecified dementia with agitation. According to the Minimum Data Set (MDS) assessment dated [DATE], R704 had severe cognitive impairment, received scheduled and as needed (PRN) pain medication, had occasional pain and was taking opioid medication. Review of the Medication Administration Records (MARs) and the corresponding Control…

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 the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 2/4/25 between 9:00 AM-9:30 AM, during an initial observation of the kitchen with Dietary Manager (DM) J, the following items were observed: In the Traulsen reach-in cooler, there was a pan of raw chicken stored directly on top of a box of cooked diced chicken, and raw pork stored on top of a box of corn chowder soup. DM J confirmed the food items were not stored properly. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) Food shall be protected from cross contamination by: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: .(b) Arranging each type of food in equipment so that cross contamination of one type with another is…

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 On 2/4/25 at 9:32 AM, Room D151-1 was observed to have privacy curtains soiled with dark brown debris. On 2/4/25 at 10:00 AM, Room D148-1 was observed to have an overbed tray table that had peeled away edges which exposed the particle board (porous material) underneath. Observations from 2/4/25 - 2/5/25 also identified concerns in the fishbowl lounge which had a large ceiling vent (approximately 3 feet x 3 feet) which had a thick layer of dusty build-up on the outside grid covering. The bathroom in the hallway just outside of the fishbowl lounge was observed to have a ceiling fan that was covered in thick, stringy, heavy dust build-up on the outside of the vent grid. On 2/5/25 at 1:30 PM, an interview was conducted with the Maintenance & Housekeeping Manager (Staff 'I'). When asked about their staffing for both housekeeping and maintenance staff, Staff 'I' reported they were fully staffed and had staff at the facility seven days a week and typically staggered the schedule either 7:00 AM to 3:00 PM or 8:00 AM to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure consistent dialysis communication documentation and assessments were completed for one (R26) of one resident reviewed for dialysis. Findings include: Review of the clinical record revealed R26 was admitted into the facility on [DATE] with diagnoses that included: acute kidney failure, end stage kidney disease (ESRD), and dependence on renal dialysis. According to the Minimum Data Set (MDS) assessment dated [DATE], this assessment failed to identify the resident was currently receiving dialysis services. Review of R26's physician's orders identified the resident had been scheduled for dialysis every Tuesday and Saturday since their admission into the facility. A physician order started on 12/10/24 documented the nursing staff were to .in the morning every Tue, Sat for ESRD please send dialysis communication sheet. Review of the resident's dialysis communication documentation which included both the electronic medical record (EMR) assessments,…

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

Based on observation, interview and record review, the facility failed to ensure appropriate storage of medications and treatments/biologicals in two of three medication rooms, one of one treatment cart, and one of four medication carts, resulting in potential for unauthorized entry, misuse, and contamination. This deficient practice has the potential to affect all residents. Findings include: On 2/5/25 at 8:37 AM, during a medication administration observation with Licensed Practical Nurse (LPN) H retrieval of medication was required from the medication room on the A/B Hallway. The medication storage room door was opened by LPN H and they proceeded to prop the door open with a red emergency (crash) cart. After retrieving medication from the A/B medication storage room, LPN H exited the medication room leaving the door propped open. On 2/5/25 at 9:07 AM, an observation of the A/B medication room remained unlocked and propped open by the emergency (crash) cart. No nursing staff was observed present in the area. On 2/5/25 at 9:24 AM, an observation of medication cart on A hall was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate assessments were completed for two (R26 and R58) of 17 residents reviewed for Minimum Data Set (MDS) assessments. Findings include: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. Link to the LTCF RAI User's Manual: https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf: .an accurate assessment requires collecting information from multiple sources .Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician . R26 Review of the clinical record revealed R26 was admitted into the facility on [DATE] with diagnoses that included: acute kidney failure, end stage kidney disease (ESRD), and dependence on renal dialysis. According to the Minimum Data Set (MDS) assessment dated [DATE], section O0110J1 which prompted the staff completing the assessment to answer yes or no if the 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 Based on observation, interview and record review, the facility failed to ensure assessments, monitoring and treatments were provided for one (R27) of two residents reviewed for non-pressure wound care. Findings include: On 2/4/25 at 9:59 AM, R27 was observed lying in their bed. A bordered gauze dressing was observed on R27's left forearm. The dressing was undated and had serosanguineous (fluids containing blood and the liquid part of blood) drainage visible approximately 1-1.5 centimeters (cm) in diameter. Another gauze dressing was observed taped to R27's left upper arm, directly above the elbow and was dated 2/2/25. R27 was asked about the bandages on their left arm. R27 explained they were not sure why the bandages were there, but had been there a while. Review of the clinical record revealed R27 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: metabolic encephalopathy, heart failure and diabetes. According to the Minimum Data Set (MDS) assessment dated [DATE], R27…

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 ensure appropriate infection control practices (handwashing and/or use of hand sanitizer) for two residents (R48, R9) out of four observed for medication administration. This deficient practice has the potential for spread of infection that could potentially affect all residents residing in the D Hall. Findings include: On 2/5/25 at 8:37 AM, a medication administration was conducted with Licensed Practical Nurse (LPN) H for R48. Hand hygiene was not observed prior to preparation, administration, and after administration of four ordered oral medications. LPN H was observed returning to the medication cart and retrieved an unopened box of ordered Artificial Tears (lubricating eye drops). The unopened box of medication was taken back to R48, hand hygiene was not observed, LPN H donned a pair of clear disposable gloves, proceeded to open the box of medication and remove the safety seal on the bottle gloved, then administered one drop into each eye of R48. After administration, LPN H voluntarily admitted that they realized they had…

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

This citation pertains to Intake Number MI00145053. Based on observation, interview, and record review, the facility failed to ensure proper sanitizing and washing practices were used to clean dishes and utensils, and failed to provide proper hand washing facilities in the kitchen. This has the potential to affect all residents who eat from the kitchen. Findings include: A review of a complaint submitted to the State Agency on 6/12/24 revealed an allegation that the facility was without hot water in the kitchen. On 7/15/24 at 9:00 AM, multiple rolling carts with meal trays were observed in the hallway. The trays contained disposable foam food containers, plastic cutlery, and reusable cups and mugs. At that time, an observation was made of the facility's kitchen. Instructions for hand washing were posted above the hand washing sink that noted Wet your hands with hot running water (at least 100 degrees F - Fahrenheit) . After several minutes of running the hot water in the sink, the water remained cold. At that time, an interview was conducted with [NAME] 'A'. [NAME] 'A' reported…

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 Number(s): MI00145115. Based on interview and record review, the facility failed to provide assistance with dressing for one (R801) of three residents reviewed for activities of daily living (ADLs). Findings include: A review of a complaint submitted to the State Agency alleged R801's clothing was not changed for two days between 6/7/24 and 6/9/24. On 7/15/24, an onsite, unannounced investigation was conducted. A review of R801's clinical record revealed R801 was admitted into the facility on 6/6/24 for hospice respite (short term placement to provide a temporary break for caregivers) and discharge home on 6/11/24 with diagnoses that included: heart failure and dementia. A review of R801's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had severely impaired cognition. A review of an Admission/readmission Assessment for R801 dated 6/6/24 revealed they were totally dependent on staff for bed mobility, transfers, and ADLs. A review of a Functional Abilities…

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 MI00142895. Based on interview and record review, the facility failed to permit one (R902) of one residents reviewed for discharge, to return to the facility following a transfer to the hospital. Findings include: On 6/4/24 a complaint received by the State Agency (SA) was reviewed alleging the facility refused to readmit one resident (R902) once medically cleared from the hospital. A clinical record review revealed R902 was admitted to the facility on [DATE] from the hospital with altered mental status, psychotic disorder with delusions, delirium, restlessness, dementia with severe agitation. A review of two Brief Interview for Mental Status (BIMS) exams calculated a score of 8/15 in January (2024) and a second BIMS of 5/15 in February (2024) indicating severe cognitive impairment for both scores. A review of an initial progress note from 1/18/24 documented R902 was living at home with their spouse and one night wandered out from the home and entered a neighbor's residence.…

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 adequate nursing staff to meet resident needs (including for Resident 17, R18 and R40), resulting in complaints of delay in care and meal delivery. This deficient practice has the potential to affect all residents within the facility. Findings include: On 01/21/2024 at 09:53AM, Initial interview with R17 was observed up in chair, watching television, appropriately dressed. This surveyor pronounced residents name, as overheard by Certified Nurse Assistant (CNA) G. R17 rolled her eyes, appeared upset and corrected this surveyor on pronunciation of first name. R17 stated the staff always pronounce my name wrong, I have told them, and they don't pay attention to what I say, and they are never around anyways. They are always short staffed. They probably just came in here now because you are here. Inquired response time when using the call light and R17 replied I gave up on that. I don't even bother using it anymore, they never respond.…

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 sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 1/21/24 between 8:40 AM-9:20 AM, during an initial tour of the kitchen, the following items were observed: There was a personal cell phone observed on the food preparation table next to the robot coupe food processor. According to the 2017 FDA food code, Section 7-209.11 Storage, Except as specified under §§ 7-207.12 and 7-208.11, Employees shall store their personal care items in facilities as specified under 6-305.11(B), and Section 6-403.11 Designated Areas, .(B) Lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, linens, and single-service and single use articles can not occur. In the dish machine room, the white caulk along where the soiled drain board meets the backsplash, was observed to be heavily soiled with a black mold-like substance. According to 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 observation, interview and record review, the facility failed to ensure handrails in main hallways were maintained in a safe condition, and ensure a fully functioning heating system to maintain comfortable temperatures (for residents R18, R25, R19, R29, R251, R250, R249), which affected multiple residents residing on the A, B and C hallways. Findings include: Handrails: On 1/21/24 at 12:17 PM, the handrail (plastic light brown colored) across from the nursing desk (in main area to go from A hall to B hall was observed to be broken with exposed sharp plastic pieces. The handrail outside the fishbowl room was also observed to be broken with exposed, sharp, plastic pieces. On 1/22/24 at 3:30 PM, the handrails remained in the same broken condition. On 1/23/24 at 12:09 PM, the Administrator was requested to provide any documentation of handrail audits, including the facility's policy on maintaining handrails in safe condition. Review of the documentation provided by the facility for the above request included only a policy titled, Handrails dated 1/11/2021 which read, .Routine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure medications were consistently administered according to professional standards of practice for three (R's 249, 18 & 25) of three residents reviewed for professional standards of practice for nurses. Findings include: R249 On 1/21/24 at 11:20 AM, R249 was observed laying on their back in bed. R249 stated how they were frustrated because they did not receive the previous day (1/20/24) evening medications until after 2AM this morning. R249 verbalized their frustration of their delayed medications and having to endure unmanaged pain all night and to have not received their sleep medication timely. Review of the medical record revealed R249 was admitted to the facility on [DATE] with diagnoses that included: injured in collision motor vehicles, fractures of ilium, lower end of left radius, ribs right side, shaft of right tibia, shaft of right fibula, sacrum, surgical neck of right humerus, injury of intra-abdominal organ, laceration…

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

Based on observation, interview and record review the facility failed to ensure medications were properly labeled, stored and secured in one medication cart and three treatment carts of two medication carts and two medication storage rooms reviewed for medication labeling and storage. Findings include: On 1/21/24 at approximately 9:05 a.m. a treatment cart in the B hall was observed unlocked and unattended by any Nursing staff. On 1/21/24 at approximately 9:08 a.m., a treatment cart in the C hall was observed to be unlocked and unattended by Nursing staff. On 1/21/24 at approximately 9:21 a.m., a treatment cart in the D hall was observed to be unlocked and unattended by any Nursing staff. On 1/22/24 at approximately 12:27 p.m., the medication cart on D-Hall was reviewed with Nurse G and revealed the following: 1. opened and undated insulin flex pen. A Solostar Tougeo pen that contained no resident name and a Solostar Apidra pen that had no resident name and 3 bottles of opened and undated artificial tears. On 1/23/24 at approximately 9:07 a.m. The medication cart on D-Hall was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00141722 Based on interview and record review, the facility failed to ensure an environment free from physical restraints for one resident (R299) of one resident reviewed for Restraints. Findings include: On 1/21/24 a facility reported incident (FRI) was reviewed in which R299 was physically restrained to a chair on 12/9/23 and to their bed on 12/12/23. On 1/21/24 the medical record for R299 was reviewed and revealed the following: R299 was admitted to the facility on [DATE] and had diagnoses including Dementia and Psychotic disorder with hallucinations. A review of R299's MDS (minimum data set) with an ARD (assessment reference date) of 12/13/23 revealed R299's BIMS score (brief interview for mental status) was 10 indicating moderately impaired cognition. A facility reported incident and investigation pertaining to R299 being physically restrained was reviewed and revealed the following: Report date-12/13/23 .Description of Incident: At 10:00 AM on Tuesday 12/13/2023, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to consistently provide bathing and grooming needs for one dependent resident (R249) of two residents reviewed for Activities of Daily Living (ADLs). Findings include: Review of the medical record revealed R249 was admitted to the facility on [DATE] with diagnoses that included: injured in collision motor vehicles, fractures of ilium, lower end of left radius, ribs right side, shaft of right tibia, shaft of right fibula, sacrum, surgical neck of right humerus, injury of intra-abdominal organ, laceration of liver, spleen, and part of small intestine. R249 was dependent on the facility staff for all ADLs. On 1/21/24 at 11:20 AM, R249 was observed laying on their back in bed. R249 stated they were in a car accident five weeks ago and was unsure if they were going to survive. R249 stated they were transferred from the hospital to the facility for further care. The resident explained how they were currently non weight bearing and could not…

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 treatment was provided for a venous ulcer for one resident (R7) of one residents reviewed for non-pressure wound care, resulting in the potential for the wound to deteriorate/worsen. Findings include: On 1/21/24 at approximately 9:38 a.m., R7 was observed in their room laying in their bed in the supine position and appeared to be frail/vulnerable. On 1/22/24 at approximately 2:37 p.m., R7's right ankle wound was observed with Nurse G. The wound was an irregular border size with the perimeter appearing light white in color. The circumference was noted to be approximately a ½ dollar size with exposed dermis and appearing to have moist pink flesh in color. R7's right ankle wound was observed to not have any treatments applied to it nor did it have any dressing in place protecting it. Located right above the wound was another wound on the lower right extremity which had a treatment that was covered with padding and wrapped in gauze.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure interventions to prevent injury from falls were in place for one resident (R3) of three residents reviewed for accidents/hazards. Findings include: On 1/21/24 at approximately 9:12 a.m., and 1:57 p.m., R3 was observed in their room, laying in their bed. A mat was observed folded up against the wall without any mats next to R3's bed. At 1:57 p.m., R3 was queried if they were at risk of falling out of the bed and they stated Plenty, I have seizures and might roll out. That mat does not do me any good rolled up. On 1/22/24 at approximately 8:44 a.m., and 10:04 a.m., R3 was still observed in their room, laying in their bed. R3 was still observed to have their mat folded up against the wall. No mats were observed on the floor next to bed to prevent any injuries from falling. On 1/23/24 at approximately 9:09 a.m., R3 was observed in their room, laying in their bed. R3 was observed without any mats next to their bed. R3's mat was still…

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 catheter care was completed per plan of care and coordination of surgical follow-up for one (R25) of two residents reviewed for urinary catheter care. Findings include: On 1/21/24 at 9:05 AM, an interview was conducted with R25 at bedside. During that time, the resident was asked about their urinary catheter and when they pulled the drainage bag from the walker beside the bed, the bag was completely full and urine was backing up the tubing. R25 reported a history of frequent urinary tract infections (UTI), and a prolapsed uterus and bowel. When asked about how often the staff checked on the amount in the drainage bag, R25 reported the staff rarely did that and most of the time they took care of emptying it themselves. Review of the clinical record revealed R25 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Grade IV Rectocele (pelvic organ prolapse) and neuromuscular…

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 and interviews, the facility failed to provide consistent professional standards of practice regarding colostomy care for one (R249) of one resident reviewed for colostomy care. Findings include: On 1/21/24 at 11:20 AM, R249 was observed lying on their back in bed. R249 stated they were in a car accident five weeks ago and was unsure if they were going to survive the accident. R249 stated they woke up in the Intensive Care Unit (ICU) of the hospital post multiple surgeries and had obtained multiple fractures throughout their body as a result of the motor vehicle accident. R249 stated their colostomy bag was a result of one of the many surgeries they endured while hospitalized . R249 began to verbalize their frustration with the facility care stating . they're not consistent. One day it could be great and the next could be the worse day ever . R249 stated how they were informed that if they observed their colostomy bag getting bigger in size, they needed to alert staff, so that the bag could be emptied. R249 stated a few days ago they noticed their colostomy bag…

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

Based on observation, interview, and record review, the facility failed to ensure freedom from significant medication errors for one two residents (R#'s 705 and 706) of four residents reviewed for medications, resulting in R705 receiving R706's narcotic medications requiring the use of narcan (an opioid reversal treatment). Findings include: On 3/11/24 at 11:20 AM, a review of R705's clinical record revealed an incident note dated 3/5/24 entered into the record by Nurse 'J' that read, .Resident received Oxycodone (opioid pain medication) .and gabapentin (controlled substance for the treatment of neuropathy) .at 1300 (1PM). The error was not identified until 1700 (5 PM) when the nurse went to the resident's room and observed the resident very drowsy while sitting up his wheelchair .narcan .via IM (intramuscular) injection & vitals every 30 minutes . A review of a facility provided Incident/Accident Report dated 3/5/24 was reviewed and also documented the medication error. On 3/11/24 at 11:35 AM, a review of R705's physician's orders was conducted and revealed R705 did not have orders…

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 built-up utensils were provided during meals for one resident (R3) of five residents reviewed for dining. Findings include: On 1/21/24 at approximately 9:12 a.m., R3 was observed in their room, laying in bed attempting to eat the breakfast meal with their fingers. R3 was observed to have regular plastic silverware. At that time, R3's meal ticket was observed which documented they were supposed to have been provided built-up utensils. On 1/21/24 at approximately 1:31 p.m. R3 was observed in their room, attempting to eat the lunch meal. R3 was observed to still have standard plastic silverware. No built-up utensils were provided during the meal. On 1/22/24 at approximately 1:19 p.m. R3 was observed in their room, attempting to eat lunch. R3 was observed to be using their hands to eat and was queried if they had any built-up utensils and they reported the facility does not remember they needed to have those utenils, but indicated they…

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 educate, offer and/or maintain the COVID-19 vaccination status for one staff (Certified Nursing Assistant - CNA K) of one staff reviewed for the COVID-19 vaccine. Findings include: On 1/23/24 at 12:33 PM, the Director of Nursing (DON) who also serves as the facility's Infection Control Nurse and Preventionist (ICNP) was asked to provide the education and the consent for the offering and/or refusal of the COVID-19 vaccination for (CNA) K. At approximately 1:10 PM, the DON returned and stated they could not provide the documentation of the facility to have educated or offer CNA K on the COVID-19 vaccine. The DON stated the facility is not currently offering the COVID-19 vaccine to any of their staff. A COVID-19 immunization policy was requested at the start of survey and again on 1/21/23 at 2:43 PM, however a policy was not provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to timely address an infestation of ants in the room occupied by R18, resulting in uncomfortable living conditions. Findings include: On 1/21/24 at 10:30 AM, an interview was conducted with R18 in their room at bedside. The resident was observed to be wearing oxygen via a nasal cannula that was connected to an oxygen concentrator. Next to this oxygen concentrator, a nebulizer machine was observed stored on the floor which had a folded up towel underneath and the nebulizer mask was observed hooked around and resting on the portion of the power supply cord that was near the wall outlet it was plugged into. There were multiple ants observed on the surrounding floor. When asked about the ants, R18 reported they had concerns with ants and the staff had been aware of this since last Saturday (1/13/24). The resident showed pictures they had taken on their cell phone and confirmed there were ants on the floor as well as on the bed linens. R18 stated, I feel them crawling 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.

This citation pertains to intake MI00142175 Based on observation and interview, the facility failed to maintain the heating units on the C hall, resulting in cold ambient air temperatures in the building and resident complaints. Findings include: On 1/18/24 at 11:00 AM, the facility Administrator was queried about the alleged complaint that the heating units were not functioning properly. The Administrator confirmed that the units on the C unit were blowing some air, but that they would frequently go into standby mode, so they were not able to maintain the temperatures in the resident rooms. The Administrator further stated that they had offered the residents on the C unit the opportunity to change rooms until the problem could be fixed, but that they all refused a room transfer. On 1/18/24 at 11:15 AM, Maintenance Supervisor A was queried about the heating units in the building. Maintenance Supervisor A stated that on 1/14/23, he received a call from the facility that the heating units on the C unit were not functioning properly. Maintenance Supervisor A stated that a repair…

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 citation pertains to intake #MI00139331 Based on interview and record review, the facility failed to ensure services met professional standards for medication administration and proper disposal of a fentanyl pain patch for one resident (R502) of two residents reviewed for administration and disposal of fentanyl patches, resulting in verbalized complaints and feelings of frustration. Findings include: A complaint was received by the State Agency that alleged R502's fentanyl patches were inappropriately applied. On 9/19/23 at 1:10 PM A review of R502's closed clinical record was conducted and revealed a progress note dated 8/30/23 that read, .Notified by nurse that resident's (family) wished to speak to manager and stated that there was an old Fentanyl patch stuck by tape to the right side/armpit area of resident. Upon examination we found that the patch was an old patch folded over and stuck to her underarm with medical tape .Nurse manager writer spoke with (family) informing (them) that the old patch should in-fact have been discarded properly . On 9/19/23 at 3:07 PM, an…

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 citation pertains to intake #MI00138844. Based on observation, interview, and record review, the facility failed to ensure timely answering of a call light for one resident (R501) of three residents reviewed for call lights, resulting in complaints of frustration and unmet resident care needs. Findings include: A complaint was received by the State Agency that alleged staff were not answering the call lights in a timely manner. On 9/19/23 at 11:00 AM, an interview was conducted with R501. During the interview R501 said their call light had been on for a half an hour and no one had answered it. R501 said they wanted the nurse to bring them some ibuprofen. On 9/19/23 at 11:05 AM, the call light monitoring system at the nursing station was reviewed. It indicated R501's call light had been activated at 10:35 AM and had not been answered. It was observed multiple staff members were up and down the halls and around the nursing station at the time R501's call light was activated, but no one was observed to check the monitor for active call lights. At that time, an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00138844 Based on observation, interview and record review, the facility failed to ensure a transportation to an outside consultation appointment for one resident (R501) of three resident's reviewed for outside appointments, resulting in the cancellation of the appointment and feelings of frustration. Findings include: A complaint was received by the State Agency that alleged R501 missed an outside consultation appointment because no transportation was available. On 9/19/23 at 11:00 AM, 501 was observed in their room. R501 was observed to be involuntarily tapping their legs and had a pronounced tremor in their hands and arms. At that time, R501 was asked if they had any concerns and said they had missed a scheduled neurology appointment to be assessed for Parkinson's Disease on 9/6/23 because transportation had not been set up. A review of R501's progress notes was conducted and revealed a note dated 8/1/23 that read, .This writer contacted (Dr. 'B') per resident and family…

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

This citation pertains to Intake Number(s): MI00136539. Based on observation, interview, and record review, the facility failed to ensure the resident's environment was maintained in a clean and comfortable manner, ensure there was an adequate supply of linens (towels, wash cloths, and bed sheets), and ensure resident's clothing was not damaged when laundered resulting in odors, damaged clothing, towels and washcloths not being available for resident care, and residents' bed sheets not being changed regularly. This affected five (R805, R807, R810, R811, R812, R813) of seven residents reviewed for a clean and comfortable environment and had the potential to affect all residents who resided in the facility. Findings include: On 8/1/23 at 8:39 AM, an observation of the D Unit was conducted. The following was observed: 1. A plastic bag full of dirty incontinence briefs and linens was observed on the floor in the hallway where three residents, including R811, were seated in their wheelchairs, eating breakfast. 2. The trash can in the D Hall shower room was over flowing with trash and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00138552. Based on interview and record review, the facility failed to report an incident of resident to resident verbal abuse to the Abuse Coordinator for two (R804 and R805) of five residents reviewed for abuse. Findings include: Review of R804's clinical record revealed R804 was admitted into the facility on 3/9/22, was discharged to the hospital on 7/15/23, and readmitted on [DATE] with diagnoses that included: schizoaffective disorder bipolar type, post traumatic stress disorder, and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R804 had intact cognition and verbal behaviors. Review of a Nursing Progress Note dated 5/29/23 and written by Unit Manager, Nurse 'J', revealed, LATE ENTRY: .the resident approached another resident to attempt to stop negative disrespectful behavior toward others. he was then called names and talked to disrespectfully by resident. he then was told to shut up and mind his own business and some other curse…

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.