Mountain View Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) staff wore appropriate Personal Protective Equipment (PPE) when entering the rooms of 2 of 14 coronavirus (COVID-19) positive residents (Residents #108 and #58) and 2) enhanced barrier precautions (EBP) were appropriately implemented and a staff member performed hand hygiene appropriately when performing wound care for 1 of 26 sampled residents (Resident #2). The deficient practice had the potential to spread infectious illnesses to vulnerable residents in the facility and result in a resident developing an infection from a staff member's lack of hand hygiene or failure to follow appropriate EBP. Findings include:Resident #108 Resident #108 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of acute systolic heart failure. A physician's order, dated 01/11/2026, documented Droplet Precautions were necessary when a patient infected with a pathogen such as influenza,…

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

Based on interview, record review, and document review, the facility failed to ensure a staff member received screening and education on the Sars Coronavirus 2019 (COVID-19) vaccine for 1 of 1 staff sampled for COVID-19 vaccine review. This deficient practice had the potential to result in a staff member not having the opportunity to receive the vaccine or education on the risks and benefits of the vaccine.Findings include:Employee #23Employee #23 was hired as a Registered Nurse (RN) with a start date of 08/31/2023.On 01/15/2025 at 9:55 AM, the Infection Preventionist (IP) verbalized the facility did not have any documentation of education or screening provided to the RN and confirmed the RN had not been screened for eligibility to receive the COVID-19 vaccine.The IP verbalized the facility referred to the federal regulation as the facility policy for screening and educating staff on the COVID-19 vaccine.

Based on personnel record review, interview, and document review, the facility failed to ensure initial behavioral health care training, related to dementia, was completed timely for 2 of 20 sampled employees (Employee #9 and #10). This deficient practice had the potential to prevent residents with dementia care needs from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.Findings include:Employee #9Employee #9 was hired as a Certified Nursing Assistant (CNA) on 06/16/2025.Employee #9's personnel record documented initial behavioral health care training for dementia completed on 11/01/2025.Employee #10Employee #10 was hired as a Speech Language Pathologist on 06/27/2025.Employee #10's personnel record documented initial behavioral health care training for dementia completed on 10/30/2025.On 01/15/2026 at 9:50 AM, Human Resources/Payroll explained all employees, contracted employees, and agency staff were to complete behavioral health training related to dementia within the first 30 days of hire and annually thereafter. The Human…

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 clinical record review, document review, and interview, the facility failed to notify the on-call medical provider after a resident experienced a fall with injury, resulting in bruising to the forehead for 1 of 25 sampled residents (Resident #2). This deficient practice had the potential to result in delayed identification and treatment of serious complications, including intracranial bleeding, for a resident receiving anticoagulation therapy.Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, muscle weakness, generalized, difficulty in walking, paroxysmal atrial fibrillation, chronic combined systolic congestive and diastolic congestive heart failure, and long-term and current use of anticoagulants. Resident #2's Care Plan dated 11/11/2021 and updated 08/30/2025, documented the resident was receiving an anticoagulant related to atrial…

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 personnel record review, interview and document review, the facility failed to ensure initial elder abuse prevention training was completed timely for 1 of 10 sampled employees (Employee #8). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include:Employee #8Employee #8 was hired as a Certified Nursing Assistant on 11/01/2025.Employee #8's personnel record lacked documented evidence elder abuse prevention training was completed upon hire.On 11/25/2025 at 2:36 PM, the Administrator verbalized abuse training was to be completed within the first orientation. Staff were not permitted to work on the floor prior to the completion of abuse training. All staff were required to complete abuse training. The Administrator confirmed Employee #8 lacked timely elder abuse training.The facility policy titled Abuse Training, updated 10/2022, documented facility staff, contract staff and routine volunteers were trained on abuse prevention, reporting, and intervention upon hire, annually and periodically thereafter in accordance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview, and document review, the facility failed to ensure the safety of a resident with wandering behaviors from elopement from the facility for 1 of 16 sampled residents (Resident #13). The deficient practice had the potential for physical and psychosocial harm to the resident. Findings include: Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including memory deficit following other cerebrovascular disease, unspecified dementia, unspecified severity, with other behavioral disturbance, and cognitive communication deficit. Elopement Risk Evaluation dated 03/04/2025, documented Resident #13 had a history of wandering, had verbalized the desire to leave the facility, and was seeking out family members placing the resident at significant risk of an unsafe situation related to the resident's diagnosis of dementia with behaviors. Care Plan dated 03/06/2025, documented Resident #13 was an elopement risk, wandered aimlessly related to…

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

Based on observation, interview, and document review, the facility failed to ensure 1) a medication cart containing resident medications was secure, 2) an open multi-dose vial had the date opened and initials of the first person to use the vial written on it in 1 of 2 medication storage rooms reviewed and 3) outdated medications were removed from 3 of 3 medication carts reviewed and 1 of 2 medication storage rooms reviewed. The deficient practice could have facilitated unauthorized access to medications in the cart and had the potential for outdated/expired medications to be administered to residents. Findings include: Unsecured Medications On 11/07/2024 at 9:14 AM, the Director of Nursing Services (DNS) verbalized medication carts should be secure when not in use. On 11/07/2024 at 10:24 AM, an unattended medication cart in the 100 hall was unlocked. A resident was standing next to the unlocked medication cart. On 11/07/2024 at 10:27 AM, a Registered Nurse (RN) returned to the unsecured medication cart and confirmed the medication cart was unlocked. The RN confirmed a resident 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 observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities and 14 medication errors. The medication error rate was 53.85%. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 11/07/2024 at 8:07 AM, a Licensed Practical Nurse (LPN) began preparing to administer medications to Resident #4. Among the medications prepared were the following: -Cholecalciferol (Vitamin D) 1000 units, two tablets. -Loratadine 10 milligrams (mg), one tablet. -Fish Oil 1000 mg, one capsule. -Multivitamin, one tablet. -Fluticasone 50 micrograms (mcg) per spray. -Vitamin B1 (Thiamine) 100 mg, one tablet. -Lisinopril 10 mg, one tablet. On 11/07/2024 at 8:15 AM, the LPN administered the prepared medications…

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, clinical record review, interview, and document review the facility failed to ensure a resident's right to self determination was respected when the facility failed to inform a new Certified Nursing Assistant (CNA) of the resident's wishes not to be disturbed for care during the night. The CNA continued to attempt to turn the resident after the resident had asked the CNA to stop, resulting in bruising to the resident's thigh for 1 of 28 sampled residents (Resident #23). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including other specified arthritis, unspecified site, essential primary hypertension, and chronic obstructive pulmonary disease. An initial Facility Reported Incident (FRI) submitted to the State Agency (SA) on 10/29/2024, documented Resident #23 complained of being provided rough care by a CNA on 10/26/2024. The CNA was identified, and the date of the incident was determined to be 10/27/2024. Resident #23's Comprehensive Care…

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, clinical record review and document review, the facility failed to ensure a comfortable, homelike environment when staff were reported as being loud and disruptive to a resident's sleep during the night shift for 1 of 28 sampled residents (Resident #112). Findings include: Resident #112 Resident #112 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including generalized anxiety disorder and insomnia, unspecified. On 11/04/2024 at 2:03 PM, Resident #112 verbalized the resident was concerned about staff waking the resident up in the middle of the night. Resident #112 explained night shift staff were loud, and the resident often heard staff talking in the hallway about staff's personal lives and other residents' care. The resident had been offered to move rooms as the resident was previously near the nurses' station however the resident reported the noise level on the night shift had not improved since the resident moved to another room. The resident verbalized…

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 clinical record review and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 28 sampled residents (Resident #27). This deficient practice had the potential to deprive the resident of a person-centered care plan relative to their current health management needs. Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of other low back pain. Resident #27's quarterly MDS assessment dated [DATE], section J1900 (Health Conditions-Number of Falls Since Prior Assessment) documented Resident #27 had two falls with no injury, one fall with injury, and two falls with major injury since the last assessment. Resident #27's progress notes documented the resident fell once on 09/14/2024 but lacked documented evidence any other falls occurred in 2024. On 11/07/2024 at 12:01 PM, the MDS Coordinator Licensed Practical Nurse (LPN)verbalized using the Resident Assessment Instrument (RAI)…

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, clinical record review and document review the facility failed to provide showers for 1 of 28 sampled residents (Resident #108). The deficient practice had the potential to negatively impact the resident's overall well-being. Findings include: Resident #108 Resident #108 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including spinal stenosis, cervical region, chronic pain syndrome, and difficulty in walking. On 11/04/2024 at 4:07 PM, Resident #108 verbalized the resident did not get showers or bed baths. Resident #108's Comprehensive Care Plan dated 09/09/2024, documented shower two times weekly. On 11/06/2024 at 2:11 PM, a Certified Nursing Assistant (CNA)/Shower Aid verbalized residents should receive two showers a week, but the CNA was aware the Resident #108 preferred showers more often. Resident #108 only received showers once a week, although the resident's preference was three times a week. The resident did not refuse showers when offered. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interview, and document review, the facility failed to ensure 1) a resident's significant surgical wounds were evaluated weekly for 1 of 28 sampled residents (Resident #67), 2) a resident's change in condition was reported timely to a physician for 2 of 28 sampled residents (Resident #36 and #62) and 3) ensure a resident's blood sugar levels were checked according to a physician's order for 1 of 28 sampled residents (Resident #52). The deficient practices had the potential to result in 1) overlooked skin integrity decline, 2) a change in condition going unmonitored, placing residents at risk for infection to spread and for poor clinical outcomes, and 3) a resident experiencing hyperglycemia (elevated blood sugar) or hypoglycemia (low blood sugar) without adequate monitoring and intervention. Findings include: Wound Evaluations Resident #67 Resident #67 was admitted to the facility on [DATE], with a diagnosis of unspecified open wound of abdominal wall, unspecified…

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, clinical record review and document review the facility failed to ensure oxygen was administered according to a physician's order for 1 of 28 sampled residents (Resident #80). This deficient practice had the potential to cause worsening of the resident's diagnosed chronic obstructive pulmonary disease. Findings include: Resident #80 Resident #80 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified bacterial pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease with acute exacerbation. On 11/04/2024 at 8:44 AM, Resident #80 was lying in bed and receiving Oxygen via nasal cannula (NC). The resident's Oxygen concentrator was set at three liters per minute (LPM). Resident #80 verbalized Resident #80 wore Oxygen continuously and was supposed to be receiving two LPM. On 11/05/2024 at 4:04 PM, Resident #80 was lying in bed and receiving Oxygen via NC. The resident's Oxygen concentrator was set at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review the facility failed to identify triggers for a resident diagnosed with post-traumatic stress disorder (PTSD) for 1 of 28 sampled residents (Resident #52). This deficient practice placed the resident at risk for re-traumatization. Findings include: Resident #52 Resident #52 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder, chronic and paranoid schizophrenia. Resident #52's Care Plan documented Resident #52 was at risk for feelings of trauma or re-traumatization due to a diagnosis of PTSD. Goals included Resident #52 would be free of feelings of trauma or re-traumatization and would be safe and supported. Interventions included assisting Resident #52 with obtaining mental health or other services to support the resident as indicated and displaying warmth, compassion, and non-judgmental approach. On 11/06/2024 at 11:30 AM, a Licensed Practical Nurse (LPN) verbalized residents' behaviors were monitored…

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, clinical record review and document review, the facility failed to ensure 1) resident information was not visible on an unattended computer screen, and 2) records were accurate for 1 of 28 sampled residents (Resident #62). Findings include: On 11/03/2024 at 12:24 PM, a computer screen on an unattended medication cart in the 100 hall displayed resident information. On 11/03/2024 at 12:25 PM, a Licensed Practical Nurse (LPN) returned to the medication cart and verbalized the computer screen should not display resident information. The LPN confirmed the computer screen was unlocked and unattended with resident information on display. On 11/06/2024 at 4:35 PM, a computer screen on an unattended medication cart in the 100 hall displayed resident information. On 11/06/2024 at 4:36 PM, a Registered Nurse (RN) returned to the cart and verbalized computer screens should be locked when not attended and confirmed the computer screen displayed resident medical records. On 11/07/2024 at 9:14…

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, clinical record review, and document review the facility failed to ensure ordered Enhanced Barrier Precautions (EBP) were implemented for a resident with chronic pressure ulcers for 1 of 28 sampled residents (Resident #60). The deficient practice had the potential for spreading infectious illnesses to the vulnerable resident. Findings include: Resident #60 Resident #60 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus with hyperglycemia and pressure ulcer of right heel, stage three. A physician's order dated 02/20/2024, documented Enhanced Barrier Precautions (EBP) every shift for wounds. Resident #60's care plan revised 10/30/2024, documented a potential and actual impairment to skin integrity to include a healing stage three pressure ulcer to right heel. An intervention documented EBP due to wounds. On 11/03/2024 at 10:45 AM, EBP signage was not posted at the entrance of Resident #60's room. On 11/07/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review, the facility failed to ensure 1 of 5 residents (Resident #392) reviewed for vaccinations, including influenza vaccines (Resident #392) was adminitstered the vaccine after the resident's guardian had consented for the vaccine to be administered. The deficient practice had the potential to place the resident at risk for not being protected against serious illness. Findings include: Resident #392 Resident #392 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, type II diabetes mellitus, and adult failure to thrive. Resident #392's State Immunization Record documented the resident last received an influenza vaccine on 12/27/2023. Resident #392's clinical record included a Resident Multi-Vaccine Consent Form. The form was signed and dated by the resident's guardian on 10/29/2024, giving consent for the resident to receive an influenza vaccine. The form documented the resident was eligible to recieve…

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 document review, the facility failed to accurately document the amount of a controlled substance in 2 of 2 sampled controlled substance logs and failed to ensure the discrepancies were reported to the Director of Nursing (DON). Findings include: On 11/14/23 at 2:03 PM, a controlled substance reconciliation count was completed for the 300 hall medication cart's controlled substance log with the DON and the following inaccuracies were identified. The controlled substance log documented the following: -On 11/09/23 at 8:00 AM, a 0.25 milliliter (ml) dose of morphine sulfate concentrate (morphine) was documented as administered, and 4.0 ml of the medication remained in the bottle. -On 11/09/23 at 8:00 PM, a 0.25 ml dose of morphine was documented as administered and the remaining amount was documented as 3.5 ml and should have been documented as 3.75 ml. -On 11/13/23 at 8:00 PM, documented 1.5 ml of morphine remained in the bottle. There were no additional entries in the log. A 0.25 ml dose of morphine was documented as given twice daily on 11/10,…

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, clinical record review, interview, and document review the facility failed to ensure staffing in the 300 hall memory care was sufficient to ensure timely administration of medications resulting in the failure to ensure a medication error rate of less than 5 percent (%) and the facility did not experience excessively low weekend staffing. Findings include: Timely Administration of Medications On 11/16/23 between 9:05 AM and 9:46 AM, during observation of the 300 hall memory care unit's medication administration pass, a Registered Nurse (RN) administering medications, prepared resident medications in the enclosed nurse's station to ensure resident safety. The RN explained due to the residents' cognitive deficits items on top of the medication administration cart, such as pitchers of water, juice, and pudding put the residents at increased risk of harm related to falls. There was not another staff member present at the nurse's station to assist the RN when residents came to the nurse's station for assistance. The RN had to make frequent delays in the medication…

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, clinical record review, and document review the facility failed to ensure medication was administered with an error rate of less than 5 percent (%). There were 25 opportunities and 14 medication errors. The medication error rate was 56.0 %. Findings include: Resident #60 Resident #60 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, bipolar type. Resident #60's Order Summary Report documented the following physician's order: -Olanzapine oral tablet 5 milligrams (mg), give 5 mg by mouth one time a day for schizoaffective disorder, bipolar type. Resident #60's Medication Administration Record (MAR) for November 2023, documented the following medication was due each morning at 8:00 AM: -Olanzapine 5 mg tablet. On 11/15/23 at 9:05 AM, a Registered Nurse (RN) began preparing Resident #60's morning medication for administration to the resident. On 11/15/23 at 9:09 AM, the RN entered Resident #60's room to administer the resident's morning dose of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview and document review, the facility failed to prevent resident to resident physical abuse for 1 of 12 Facility Reported Incidents (FRI) (Resident #5). Findings include: A FRI final report, dated 10/27/23, documented on 10/25/23, Resident #115 had punched Resident #5 in the stomach when attempting to exit the common room. Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia and major depressive disorder. Resident #115 Resident #115 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including psychotic disorder with delusions, unspecified mood disorder and unspecified psychosis. Resident #5's Interdisciplinary Note dated 10/26/23, documented on 10/25/23, Resident #5 was involved in a resident-to-resident altercation. A Certified Nursing Assistant (CNA) notified the nurse, Resident #5 was witnessed getting hit by Resident #115 with a closed fist when Resident #115…

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, record review, and document review the facility failed to document an investigation of alleged abuse for 1 of 25 sampled residents (Resident #114). Findings include: Resident #114 Resident #114 was admitted to the facility on [DATE], with diagnoses including spinal stenosis, chronic obstructive pulmonary disease, unspecified, generalized anxiety disorder, and major depressive disorder, recurrent severe without psychotic features. On 11/13/23 at 3:15 PM, Resident #114 verbalized a facility staff member had thrown water on the resident a couple of days prior. Resident #114 verbalized they threw the water back at the staff member and had been frustrated due to waiting 45 minutes for a response to the call light. The resident recalled the staff member was not a nurse. On 11/14/23 at 9:54 AM, Resident #114 recalled telling a nurse on the day of the incident about the staff member throwing water at them but did not file a grievance. On 11/15/23 at 4:09 PM, a Registered Nurse (RN) verbalized if a…

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 the accuracy of a Minimum Data Set 3.0 (MDS) for 1 of 25 sampled residents (Resident #114). Findings include: Resident #114 Resident #114 was admitted to the facility on [DATE], with diagnoses including spinal stenosis, chronic obstructive pulmonary disease, unspecified, generalized anxiety disorder, and major depressive disorder, recurrent severe without psychotic features. On 11/13/23 at 3:24 PM, Resident #114 verbalized their dentures were broken the second day in the facility. The resident recalled the facility informed them a dental appointment would be made but no one had followed up. A Care Conference note dated 08/08/23, documented the resident had upper and lower dentures in need of repair. A Social Service admission and History Evaluation note dated 08/08/23, documented the resident had broken dentures - (upper and bottom) dental to follow. Resident #114's MDS Sectiom L0200 Oral/Dental Status, dated 08/14/23, lacked documentation 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, clinical record review, and document review, the facility failed to ensure a resident requiring assistance with nail care had the need care planned and a resident's care planned interventions for chronic pain were implemented for 2 of 25 sampled residents (Resident #29 and #16). Findings include: Resident #29 Resident #29 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, contracture, left hand, and muscle weakness (generalized). On 11/13/23 at 8:46 AM, the resident was sitting on the side of the resident's bed and was not wearing shoes or socks. The resident's toenails were very overgrown. The resident's clinical record lacked documentation of a care plan to address the resident's need for assistance with nail care. On 11/15/23 at 10:19 AM, Resident #29 was standing at the nurse's station. The resident had no shoes or socks on, and the resident's toenails appeared long, thick, and yellowed. On 11/15/23 at 10:41 AM, the Licensed…

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, clinical record review and document review, the facility failed to offer a non-English speaking resident translation services as care planned for 1 of 25 sampled residents (Resident #97). Findings include: Resident #97 Resident #97 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, dementia unspecified, and adult failure to thrive. Resident #97's Comprehensive Care Plan documented Resident #97 had a communication problem related to a language barrier as Resident #97 speaks Spanish and interventions included use of a language (phone) line. On 11/15/23 at 10:07 AM, a Certified Nursing Assistant (CNA) verbalized there were two residents who were Spanish speaking only. The CNA explained there was always a staff member on the hall who speaks Spanish. The CNA verbalized sometimes having to provide translation with assessments for the nurses. The CNA confirmed not using the translation service as the CNA 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 observation, interview, clinical record review, and document review, the facility failed to ensure a resident requiring assistance with nail care was provided with care to prevent the resident's toe nails from becoming overgrown for 1 of 25 sampled residents (Resident #29). Findings include: Resident #29 Resident #29 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, contracture, left hand, and muscle weakness (generalized). On 11/13/23 at 8:46 AM, the resident was sitting on the side of the resident's bed and was not wearing shoes or socks. The resident's toenails were very overgrown. The resident's clinical record lacked documentation of an assessment of the resident's nails or a care plan to address the resident's need for assistance with nail care. On 11/15/23 at 10:19 AM, Resident #29 was standing at the nurse's station. The resident had no shoes or socks on, and the resident's toenails appeared long, thick, and yellowed. On 11/15/23 at 10:41 AM, 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 interview, personnel record review and document review, the facility failed to ensure Cardio-Pulmonary Resuscitation (CPR) with First Aid training was completed for 1 of 5 sampled Licensed Nurses (Employee #2). Findings include: Employee #2 Employee #2 was hired on [DATE], as the Director of Nursing (DON). The DON's personnel record documented evidence of CPR with First Aid training was last completed on [DATE], and had expired [DATE]. The DON's personnel record lacked documented evidence of CPR with First Aid training for [DATE]. On [DATE] at 10:52 AM, the Human Resources Manager verbalized CPR was required to be taken by all licensed nurses upon hire and again upon the expiration date. The facility policy titled Cardiopulmonary Resuscitation (CPR), last updated 09/2017, documented all licensed nurses employed by the center were required to have current CPR certification.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a history of a pressure ulcer and determined to be at risk for the development of a pressure ulcer received wound care per physician and the facility policy for 2 of 25 sampled residents (Resident #64 and #54). Findings include: Resident #64 Resident #64 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, pressure ulcer of left heel, unstageable, pressure ulcer of other site, stage two, pressure ulcer of right hip, stage three, and pressure ulcer of sacral region, stage four. A Weekly Skin Evaluations dated 10/25/23, documented three different pressure ulcers. An unstageable pressure ulcer on the left heel, a stage two pressure ulcer on the left outer ankle, and a stage four pressure ulcer on the sacrum. A care plan for Resident #64, initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review, the facility failed to ensure a bed was in the low position per physician's orders and followed after a resident was identified as a high risk for falls and had a history of actual falls, in an attempt to prevent future falls for 1 of 25 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including other sequalae of other cerebrovascular disease, conversion disorder with seizures or convulsions and vascular dementia, severe, with psychotic disturbance. On 11/13/23 at 9:41 AM, Resident #1 was sleeping in bed and the bed was in the highest position. A Care Plan initiated on 01/19/21, and revised on 09/20/22, documented the resident was at risk for falls related to confusion, gait and balance problems, incontinence, psychoactive drug use, unaware of safety needs and wondering. The resident's last actual fall was documented on 09/20/22. Fall interventions 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 Based on observation, interview, clinical record review, and document review, the facility failed to ensure an attempt was made to schedule a timely follow up appointment with a Urologist for a resident with a urinary catheter for 1 of 25 sampled residents (Resident #113). Findings include: Resident #113 Resident #113 was admitted to the facility on [DATE], with diagnoses including overactive bladder, unspecified urinary incontinence, and major depressive disorder, single episode, unspecified. On 11/13/23 at 8:43 AM, Resident #113 was sitting up on the side of the resident's bed. The resident held up the resident's catheter bag and became tearful. The resident asked if the resident could take it out. On 11/13/23 at 10:10 AM, the representative for Resident #113 verbalized the resident had gone to the Emergency Department (ED) and had the catheter inserted for a blockage. The representative verbalized the facility was supposed to schedule an appointment with a Urologist for Resident #113 to determine 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, clinical record review, and document review, the facility failed to ensure a resident was medicated for pain prior to procedures as care planned for 1 of 25 sampled residents (Resident #16). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pressure ulcer of sacral region, stage four, diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, and major depressive disorder, recurrent, unspecified. On 11/13/23 at 9:10 AM, the resident verbalized the resident had a wound on the resident's back and the dressing changes frequently caused the resident pain. A care plan for Resident #16, revised 09/20/23, documented the resident had chronic pain and received Tylenol as needed. Analgesia would be administered one half hour before treatments or care. An Order Summary Report for Resident #16 documented the following: - acetaminophen (Tylenol) suppository 650…

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, clinical record review and document review the facility failed to ensure an informed consent was obtained prior to installation of grab bars for 1 of 25 sampled residents (Resident #69). Findings include: Resident #69 Resident #69 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other specified fracture of right pubis, subsequent encounter for fracture with routine healing, traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, unspecified dementia, mild, without behavioral disturbance, and muscle weakness (generalized). On 11/14/23 at 7:57 AM, Resident #69's bed had grab bars on both sides. A Device Informed Consent, dated 07/12/23, documented the resident was informed of the risks and benefits of right-side grab bar use and device did not restrict movement. A bed rail evaluation dated 08/17/23, documented bilateral grab bars were recommended. Resident #69's care plan documented the resident was at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review the facility failed to obtain informed consent prior to administration of a psychotropic medication, ensure psychotropic medications were ordered and administered to treat a specific, diagnosed condition for 1 of 25 sampled residents (Resident #54) and ensure a resident on a psychotropic medication had a gradual dose reduction (GDR) for 1 of 25 sampled residents (Resident #22). Findings include: Resident #54 Resident #54 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including aftercare following joint replacement surgery, dysphagia following cerebral infarction, unspecified dementia, mild, with other behavioral disturbance, and Alzheimer's disease, unspecified. Resident #54's Medication Administration Record (MAR) documented: - Start date of 04/18/23, hydroxyzine hydrochloride (HCl) Oral Tablet 25 milligrams (mg) (Hydroxyzine HCl) Give 1 tablet by mouth every eight hours as needed for Agitation - Getting out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and document review the facility failed to ensure a dental consult was scheduled for damaged dentures for 1 of 25 sampled residents (Resident #114). Findings include: Resident #114 Resident #114 was admitted to the facility on [DATE], with diagnoses including spinal stenosis, chronic obstructive pulmonary disease, unspecified, generalized anxiety disorder, and major depressive disorder, recurrent severe without psychotic features. On 11/13/23 at 3:24 PM, Resident #114 verbalized their dentures had broke the second day in the facility. The resident recalled the facility informed them a dental appointment would be made but no one had followed up with the resident. A Care Conference note dated 08/08/23, documented the resident had upper and lower dentures in need of repair. A Social Service admission and History Evaluation note dated 08/08/23, documented the resident had broken dentures - (upper and bottom) dental to follow. Resident #114's care plan reflected 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 interview, observation, clinical record review, and document review, the facility failed to provide meals based on resident's allergies for 1 of 25 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and re-admitted [DATE], with diagnoses including schizoaffective disorder, bipolar type, generalized anxiety disorder and metabolic encephalopathy. The diagnosis of celiac disease was added on 10/20/23. Food Preferences Record, dated 04/17/23, lacked documented evidence of celiac disease for Resident #3. Resident #3's behavioral health solutions psych progress notes from 04/25/23 to 09/25/23 documented Resident #3's gluten allergy. On 11/15/23 at 2:38 PM, the Registered Dietician (RD) explained all nutritional assessments were completed by the RD. The RD confirmed the facility was not aware of a gluten allergy prior to Resident #3's re-admission on [DATE]. On 11/15/23 at 4:16 PM, the Director of Nursing (DON) verbalized medical records 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 observation, interview, clinical record review, and document review, the facility failed to ensure transmission-based precautions (TBP) were initiated and discontinued per facility policy and staff were able to explain the reason a resident was on TBP for 1 of 25 sampled residents (Resident #31). Findings include: Resident #31 Resident #31 was admitted to the facility on [DATE], with diagnoses including non-ST elevation (NSTEMI) myocardial infarction, type two diabetes mellitus without complications, and personal history of COVID-19. On the mornings of [DATE], [DATE], and [DATE], a sign was posted on the outside of the resident's door documenting the following: - Contact Precautions (in addition to Standard Precautions). Visitors: Report to nurse before entering. An order dated [DATE], documented droplet precautions were necessary when a patient infected with a pathogen, such as influenza, pertussis, mumps, and respiratory illnesses, such as those caused by coronavirus infections. (Extended spectrum…

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 clinical record review, interview and document review, the facility failed to prevent resident to resident abuse for 7 of 28 sampled residents (Resident #15, #16, #17, #19, #21, #22, and #28), and failed to prevent employee to resident neglect for 1 of 28 sampled residents (Resident #13). Findings include: A Facility Reported Incident (FRI) final report, dated 05/01/23, documented on 04/24/23, Resident #13 had an unwitnessed fall resulting in a fractured left hip. Resident #13 was not assessed by a nurse or given medical attention until 04/26/23 due to a Hospitality Aide and Certified Nursing Assistant (CNA) not reporting the fall. Resident #13 Resident #13 was admitted on [DATE], with diagnoses including low back pain, unspecified; age-related osteoporosis without current pathological fracture; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness (Generalized); unspecified abnormalities of gait and mobility;…

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, clinical record review and document review, the facility failed to ensure post fall interventions were implemented and followed after a fall in an attempt to prevent future falls for1 of 28 sampled residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, epilepsy, unspecified, not intractable, without status epilepticus, anoxic brain damage, not elsewhere classified, and conversion disorder with seizures or convulsions. On 05/30/23 at 9:30 AM, a Licensed Practical Nurse (LPN) explained residents who were identified as a fall risk would have fall interventions put in place in an attempt to prevent injuries if a resident had fallen. The interventions could include fall mats on each side of the resident's bed and the resident would be under close supervision to ensure all…

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, clinical record review, and document review, the facility failed to ensure a Licensed Nurse provided care for a resident post fall when a Certified Nursing Assistant (CNA) and Hospitality Aide did not notify a Licensed Nurse of a resident's fall to complete an assessment of the resident for 1 of 15 residents (Resident #13). Findings include: A Facility Reported Incident (FRI) final report, dated 05/01/23, documented on 04/24/23, Resident #13 had an unwitnessed fall resulting in a fractured left hip. Resident #13 was not assessed by a nurse or given medical attention until 04/26/23 due to a Hospitality Aide and Certified Nursing Assistant (CNA) not reporting the fall. Resident #13 Resident #13 was admitted on [DATE], with diagnoses including low back pain, unspecified; age-related osteoporosis without current pathological fracture; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness (Generalized);…

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.