Chapel Hill Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #24 was positioned properly in bed and had her meal tray placed within reach to allow the resident to eat in a timely manner following meal tray delivery. This affected one resident (#24) of seven residents reviewed for nutrition. Findings include: Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses including pneumonia, dyspnea, dysphagia, emphysema and severe protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/17/22 revealed Resident #24 required limited assistance fro two staff for bed mobility, limited assistance from one for transfers, and (staff) supervision for eating. The assessment revealed Resident #24 had moderately impaired cognition. On 11/02/22 at 11:56 A.M. observation revealed Resident #24 was lying in bed with the head of the bed up. The resident's lunch tray was observed sitting on the over bed table. The over bed table was 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, record review, facility policy and procedure review and interview the facility failed to ensure Resident #171 was provided privacy during personal (catheter) care. This affected one resident (#171) of one resident reviewed for privacy. Findings include: Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses including trigeminal neuralgia, COVID-19, Alzheimer's disease, benign prostatic hyperplasia, cognitive communication deficit, need for assistance with personal care, sepsis, urinary tract infection, delusional, major depressive disorder, dementia, hypertension, bladder neck obstruction, acute kidney failure and adult failure to thrive. Review of the October 2022 physician's orders revealed Resident #171 had an order for a urinary (Foley) catheter. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/16/22 revealed Resident #171 had severely impaired cognition. The assessment revealed the resident required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #10's medical record revealed an admission date of 03/05/19 with diagnoses including Parkinson's disease, progressive supranuclear ophthalmoplegia, palliative care, dementia in other diseases pseudobulbar affect, anxiety disorder, major depressive disorder, psychotic disorder with hallucination due to known physiological condition (dated 08/13/20), dysarthria and anarthria, cognitive communication deficit, and chronic pain syndrome. Review of the medical record for Resident #10 revealed no evidence a Pre-admission Screening and Resident Review (PASARR) was completed following the addition of the 08/13/20 diagnosis of psychotic disorder with hallucination due to a known physiological condition. Review of the 08/06/22 quarterly Minimum Data Set (MDS) 3.0 revealed the resident was noted to be moderately cognitively impaired. The assessment revealed the resident required extensive assistance from two staff for bed mobility, extensive assist from one staff for transfers, dressing, toileting,…

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

Based on observation, record review and interview the facility failed to ensure Resident #10, who required staff assistance for activities of daily living, received adequate and proper assistance with meals. This affected one resident (#10) of 22 sampled residents. Findings include: Review of Resident #10's medical record revealed an admission date of 03/05/19 with diagnoses including Parkinson's disease, progressive supranuclear ophthalmoplegia, palliative care, dementia in other diseases, pseudobulbar affect, anxiety disorder, major depressive disorder, psychotic disorder with hallucination due to known physiological condition, dysarthria and anarthria, cognitive communication deficit, and chronic pain syndrome. Review of the 08/06/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #10 was moderately cognitively impaired. The assessment revealed the resident required extensive assistance from two staff for bed mobility and extensive assistance from one staff for transfers, dressing, eating, toileting, personal hygiene, and bathing. Review of the 09/06/22 speech…

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

Based on observation, record review and interview the facility failed to ensure Resident #19, who required staff assistance for activities of daily living (ADL) care received adequate urinary/urostomy catheter care to prevent urine odors and to promptly identify symptoms of a urinary tract infection. This affected one resident (#19) of three residents reviewed for dignity. Findings include: Review of Resident #19's medical record revealed an admission date of 08/24/21 with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, dysphagia, oropharyngeal phase, dementia, and a history of urinary tract infections and bladder cancer. Review of the 08/15/22 annual Minimum Data Set (MDS) 3.0 assessment for Resident #19 revealed a Brief Interview of Mental Status (BIMS) score of 10 (out of 15) which indicated moderate cognitive impairment. The assessment revealed the resident required extensive assistance from one staff for dressing and personal hygiene, extensive assistance from two staff for transfers and toileting and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #57 was provided a physician ordered weight loss supplement, failed to ensure the resident was provided the appropriate serving size of meat during the lunch meal on 10/31/22 and failed to ensure the resident was provided adequate and timely assistance with eating. This affected one resident (#57) of eight residents reviewed for food and nutrition. Findings include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, muscle weakness, need for personal assistance, cognitive communication deficit, COVID-19, psychotic disorder, hypertension, insomnia, and depression. Review of the weight record for Resident #57 revealed an admission weight of 175 pounds on 06/10/11 and then a weight of 186 pounds on 06/11/22 and 06/12/22 and a current weight (10/27/22 note) of 160.4 for a 13.98 percent decrease. Review of the plan of care, dated 06/13/22 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide emergency dental services when Resident #51 had a broken tooth. This affected one resident (#51) of one reviewed for dental services. Findings include: Review of medical record revealed Resident #51 was admitted on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure, syncope and collapse, retinal detachment, major depressive disorder, and anxiety disorder. Review of dental care services provided revealed Resident #51 had radiographic images on 12/09/21. An appointment note, dated 06/16/22 at 11:05 A.M. revealed Resident #51 had an appointment with an oral surgeon on 06/28/22. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/06/22 revealed Resident #51 had no chipped or cracked teeth. The quarterly MDS 3.0 assessment, dated 10/04/22 revealed Resident #51 was cognitively intact. Review of a nursing progress note, dated 10/16/22 at 5:00 P.M. revealed Resident #51 requested soft foods. 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, record review, facility policy and procedure review and interview the facility failed to ensure Resident #56 received food items in bite sized pieces as ordered and beverages/drinks per his preference. This affected one resident (#54) of six residents reviewed for nutrition. Finding include: Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including dementia, suicidal ideations, major depressive disorder, generalized anxiety disorder, hemiplegia, psychosis, need for assistance with personal care, cognitive communication deficit, dysphagia, adjustment disorder, repeated falls, prostate cancer and heart failure. Review of the modification to the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/22 revealed Resident #56 had severely impaired cognition. The assessment revealed the resident required (staff) supervision for eating and received a mechanically altered diet. Review of the October 2022 physician's orders revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to properly store medication in the [NAME] unit medication cart, [NAME] unit medication cart, and [NAME] unit medication cart. This affected nine residents (#26, #35,#43, #46, #56 #61 #62, #74, #83) and had the potential to affect all residents residing in the facility. The facility census was 87. Findings Include: 1. Observation on 12/12/19 at 10:50 A.M. of the [NAME] unit medication cart with Licensed Practical Nurse (LPN) #544 revealed a bottle of artificial tears eye drops not dated when opened for Resident #26, a bottle of artificial tears eye drops not dated when opened for Resident #74, a vial of Humalog insulin not dated when opened for Resident #62, and a vial of Lantus insulin not dated when opened for Resident #35. Interview on 12/12/19 at 10:55 A.M. LPN #544 verified a bottle artificial tears eye drops not dated when opened for Resident #26, a bottle of artificial tears eye drops not dated when opened for Resident #74, a vial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #55 received his preferred number of showers per week. This affected one resident (#55) of one resident reviewed for choices. Findings include: Review of the medical record for Resident #55 revealed the resident was admitted to the facility on [DATE] with diagnoses of fracture of the right tibial, obesity, muscle weakness, pulmonary embolism, ileus, megacolon, anxiety, insomnia, depression, and psychosis. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/05/19 revealed Resident #55 had intact cognition and bathing had not occurred. An interview on 12/09/19 at 10:29 A.M. with Resident #55 indicated he was not given a choice on when or how many times a week to receive a shower. The resident indicated he was only receiving one shower a week and he would like more. Interview on 12/12/19 at 9:42 A.M. with State Tested Nursing Assistant #542 revealed Resident #55 was scheduled to have a shower on Tuesday and Friday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure advanced directives were in place for Resident #62, Resident #64 and Resident #233. This affected three residents (#622, #64 and #233) of three residents reviewed for advanced directives. Findings include: 1. Resident #233 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, muscle weakness, and hypertension. Review of Resident #233's electronic medical record and paper medical record did not reveal any advance directives. On 12/10/19 at 5:00 P.M., Registered Nurse (RN) #547 verified Resident #233 did not have any advanced directives in place. Interview with RN #547 on 12/10/19 at 2:35 P.M. revealed advance directive/code status should be obtained upon admission and entered in the physician's orders and placed in the front of the paper medical record. RN #547 also revealed until a resident's code status was determined, the code status defaults to a full code. Review of the facility policy titled, Advance Care Planning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #22's responsible party was contacted timely to discuss dental options and services available for the resident. This affected one resident (#22) of 24 residents reviewed for notification. Findings include: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, type two diabetes mellitus and major depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had severely impaired cognition scoring a three on the Brief Interview for Mental Status (BIMS) The MDS assessment also revealed Resident #22 had no broken or loose fitting teeth. Resident #22's medical record revealed an initial dental visit on 10/08/19 which Resident #22 refused to attend and a second dental visit on 11/12/19 which revealed a dental treatment plan to fill tooth #3 and a clasp was removed from tooth #15 with possible further extraction of tooth #15. However, review of…

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

Based on record review and interview the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice form (SNFABN) to Resident #44 as required. This affected one resident (#44) of three residents reviewed for beneficiary notices. Findings include: Resident #44 was admitted to the facility for skilled nursing services under Medicare part A on 10/12/19. Secondary to Resident #44's medical decline and the decision to be placed onto Hospice services, the facility issued a Notice of Medicare Non-Coverage (NOMNC) with a date of 12/02/19, which was signed by Resident #44's authorized representative on 11/29/19. Review of the facility completed SNF Beneficiary Protection Notification Review form for Resident #44 revealed the facility did not provide a SNFABN for because Resident #44 transitioned onto Hospice services. Staff interview on 12/12/19 at 9:52 A.M. with Registered Nurse (RN) #557 revealed the SNFABN form was not given because the facility did not believe the form had to be given since the family had chosen Hospice services. Review of the facility provided forms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to effectively implement their abuse policy and procedure to ensure injuries of unknown origin involving Resident #19 were thoroughly investigated and reported to the State agency. This affected one resident (#19) of one resident reviewed for accidents and injuries of unknown origin. Findings include: Review of Resident #19's medical record revealed an admission date of 09/19/19 with diagnoses that included falls with pelvic fracture, dementia and osteoporosis. Further review of the progress notes revealed on 11/12/19 Resident #19 was attending a scheduled appointment with an orthopedic surgeon for follow up care related to multiple pelvic fractures that occurred prior to admission to the facility. At this appointment, the resident indicated she had pain to her left hip. An x-ray was completed at this time and found evidence of a left femoral neck fracture. Resident #19 was admitted to the hospital and received surgical repair. Review of the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure injuries of unknown origin involving Resident #19 were reported to the State agency as required. This affected one resident (#19) of one resident reviewed for accidents and injuries of unknown origin. Findings include: Review of Resident #19's medical record revealed an admission date of 09/19/19 with diagnoses that included falls with pelvic fracture, dementia and osteoporosis. Further review of the progress notes revealed on 11/12/19 Resident #19 was attending a scheduled appointment with an orthopedic surgeon for follow up care related to multiple pelvic fractures that occurred prior to admission to the facility. At this appointment, the resident indicated she had pain to her left hip. An x-ray was completed at this time and found evidence of a left femoral neck fracture. Resident #19 was admitted to the hospital and received surgical repair. Review of the medical record prior to 11/12/19 revealed falls in the facility on 9/27/19, 10/13/19,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to accurately code the comprehensive Minimum Data Set (MDS) 3.0 assessment related to antibiotic use for Resident #1 and pressure ulcers for Resident #32. This affected two residents (#1 and #32) of 22 residents whose MDS 3.0 assessments were reviewed. Findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with the diagnoses of acute osteomyelitis, pneumonitis due to the inhalation of food and vomit, diabetes, diabetic neuropathy, acute respiratory failure, epilepsy, sepsis, cerebral infarction, mild cognitive impairment, malignant neoplasm of thyroid gland, delirium, apnea, and convulsions. Review of the five day Minimum Data (MDS) Set 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition and had not received an antibiotic medication. Review of the physician's orders for December 2019 revealed Resident #1 had an order dated 11/27/19 for intravenous 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.

Based on record review and staff interview the facility failed to ensure weights were obtained and as needed diuretic medications were administered as ordered by the physician to ensure the appropriate treatment for Resident #36 who had a diagnosis of congestive heart failure. This affected one resident (#36) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #36's medical record revealed an admission date of 02/02/16 with a diagnosis that included congestive heart failure. Review of the current physician's orders revealed daily weights were to be obtained and Zaroxolyn (diuretic medication) 2.5 milligrams (mg) was to be administered once every day as needed (PRN) for a three pound weight gain. Review of the daily weight records revealed no daily weights obtained on 12/08/19, 12/07/19, 11/29/19, 11/24/19, 10/18/19, 10/12/19, 10/05/19, 09/30/19, 09/25/19, 09/20/19 or 09/12/19. Further review of the daily weights found a three pound weight gain on 12/5/19 (3.1 pounds), 11/27/19 (3.4 pounds), 11/20/19 (4.3 pounds), 11/14/19 (6.0 pounds),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #1 received thickened liquids as ordered and Resident #6, #20, #42 and #46 received nutritional supplements as ordered to promote optimal nutrition. This affected five residents (#1, #6, #20, #42 and #46) of seven residents reviewed for nutrition and hydration. Findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with the diagnoses of acute osteomyelitis, pneumonitis due to the inhalation of food and vomit, diabetes, diabetic neuropathy, acute respiratory failure, epilepsy, sepsis, cerebral infarction, mild cognitive impairment, malignant neoplasm of thyroid gland, delirium, apnea, and convulsions. Review of the five day Minimum Data (MDS) Set 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition, required supervision with eating, was on a therapeutic diet and held food and liquids in his mouth and cheeked after meals. Review of the physician's order…

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

Based on record review and staff interview the facility failed to ensure Resident #36, who received as needed anxiolytic medications had proper physician documentation for an indication for use. This affected one resident (#36) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #36's medical record revealed an admission date of 02/02/16 with diagnoses that included anxiety, schizoaffective disorder and borderline personality. Further review of the physician's orders revealed long term use of Ativan (anxiolytic medication) one milligram (mg) every eight hours as needed (PRN) for 120 days. The PRN Ativan was reordered on 08/06/19 and 12/10/19. Further review of the medical record found no evidence of any progress notes from Resident #36's physician, nurse practitioner or psychiatrist documenting the rationale for using the PRN Ativan longer than a 14 day period. Interview with the Director of Nursing and Registered Nurse (RN) #567 on 12/11/19 at 2:20 P.M. verified there was no documentation for rationale or indication of extended PRN Ativan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #54 received therapy services as ordered after a hospitalization. This affected one resident (#54) of 18 residents reviewed for orders during the annual survey. Findings include: Resident #54 was initially admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side, and dysphagia. Resident #54's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 had moderately impaired cognition scoring a 12 on the Brief Interview for Mental Status (BIMS) and required total dependence from two people for transfers. Resident #54's medical record revealed a hospital admission on [DATE] with a readmission to the facility on [DATE]. Further review of Resident #54's hospital transfer orders dated 11/19/19 revealed orders for Physical Therapy, Occupational Therapy, and Speech Therapy. Review of Resident #54's medical record revealed no documentation 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.