Williamsburg Village Healthcare Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure rooms were equipped to assure full visual privacy for each resident for 3 (Rooms # 115, #116, #119) of 18 rooms reviewed for visual privacy.The facility failed to ensure resident rooms had full visual privacy, Rooms # 115, #116, and #119, did not have a privacy curtain. This failure could place residents at risk of being exposed during cares or when changing clothes.Findings included:Observation on 03/08/26 at 11:24 AM, of room [ROOM NUMBER] there was no privacy curtain for the resident in the bed closest to the door. There was a track mounted to the ceiling for a curtain, as well as the hanger clips, but no curtain. Observation on 03/08/26 at 11:31 AM, of room [ROOM NUMBER] there was no privacy curtain at the foot of the bed closest to the window. There was a track mounted to the ceiling for a curtain, as well as the hanger clips, but no curtain.Observation on 03/08/26 at 11:38 AM, of room [ROOM NUMBER] there was no privacy…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest for 1 of 5 residents (Resident #232), 1 of 2 kitchens (North Kitchen), and 1 of 2 halls reviewed for pest control. The facility failed to ensure the facility was free of gnats in Resident #232 room, North kitchen and 700 Hall.This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.Findings included: Observation and interview on 03/08/26 at 9:14 AM, revealed there were gnats in the kitchen, in the dishwasher area. According to [NAME] K, she was aware of gnats in the dishwashing area. [NAME] K stated dishwashers were responsible for reporting the gnats to the Dietary Manager and the Maintenance Supervisor . She stated the Maintenance staff were aware of the problem. Observation and interview on 03/08/26 at 4:00 PM, Resident #232 revealed about 8-10 gnats at his bedside table, in his orange juice and on his sandwich.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to self-administer medications if the interdisciplinary team determined that this practice was clinically appropriate for 2 of 2 residents (Resident #102 and Resident #232) reviewed for resident rights.1.The facility's interdisciplinary team failed to ensure Resident #102 was clinically appropriate to self-administer Atrovent 17mcg hfa inhaler that was with the resident in the TV room.2. The facility failed to ensure Resident #232's eye drops and arthritis pain cream, located at his bedside, was clinically appropriate to self-administer medications.These failures could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.Findings include:1. Record review of Resident #102's quarterly MDS, dated [DATE], reflected Resident #102 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #102 had a BIMS score of 07, which indicated his…

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

Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable and homelike environment, including but not limited to Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 35 residents (Residents #147) reviewed for environmental conditions.The facility failed to ensure Resident #147's ceiling plaster was not hanging from the ceiling.This failure could place residents at risk for injury and a decreased quality of life. Findings include: Observation and interview on 03/08/26 at 12:50 PM, revealed Resident #147 room ceiling plaster was peeling and hanging from the ceiling and able to see the drywall. Resident #147 stated a couple of days ago it rained, it started to peel off, and it was getting bigger. Resident #147 stated she was not sure if anyone was going to fix it. Resident #147 stated she could not recall if she notified anyone about it. Interview on 03/10/26 at 10:59 AM, CNA PP revealed she was not aware of Resident #147's ceiling. She stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 of 16 residents (Resident #54, #36) reviewed for care plans.1.The facility failed to develop a care plan for Resident #54's use of a feeding tube for nutrition or his noncompliance with physician orders which indicated Resident #54 to have nothing to eat or drink by mouth.2. The facility failed to ensure Resident #36's care plan addressed antibiotic treatment via CVC line (used to deliver medications and other treatments directly to the large central veins near heart). These failures could place residents at risk of not receiving the care required to meet their individual needs.1. Record review of Resident #54's admission MDS assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 2 of 13 residents (Resident #54 and #229) reviewed for feeding tubes .1.The facility failed to ensure Resident #54's formula and water bag was properly labeled with the resident name, name of formula, feeding rate, date, time his formula and water was administered along with the nurse's initials.2. The facility failed to follow physician's orders of providing Resident #229 with his 22-hours of feeding intake and failed to ensure the formula bag was changed on 03/08/26. These failures could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.Finding include:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 2 residents (Resident #36 and Resident #227) reviewed for intravenous medication. 1. The facility failed to ensure Resident #36, and Resident #227's intravenous medication bag and tubing were labeled with the date, time, and initials.2. The facility failed to change and maintain the integrity of Resident #36's CVC line (used to deliver medications and other treatments directly to the large central veins near heart) dressing per professional standards.3. The facility failed to follow physician orders for administering medications to Resident #227 when LVN Q administered Cefazolin 2gm intravenous medication used to treat infection.These failures could place residents at risk for medication error, delay in 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, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts (Halls 600 B nurse medication cart), 1 of 2 medication rooms (600 Hall medication room), and 1 of 5 residents (Resident #54) reviewed for labeling of drugs and biologicals.1. The facility failed to ensure expired medications were removed from the Hall 600 B medication cart and Hall 600 medication room.2. The facility failed to ensure LVN Q administered all morning medication to Resident #54. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings included: 1.Observation on 03/09/2026 at 3:30 PM, of the Hall 600 B nurse medication cart with LVN M revealed one bubble pack of ibuprofen 400mg (used to treat pain) with an expiry date of January…

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 each resident was free of any significant medication errors for 1 of 7 residents (Resident #54) reviewed for medications. The facility failed to ensure LVN Q administered Resident #54 with his morning medications resulting in significant medication errors. These failures placed residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician, which could result in exacerbation of conditions. Findings included:Review of Resident #54's MDS assessment, dated 02/23/26, reflected a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54 had a BIMS score of 10 indicating moderate cognitive impairment. Resident #54's diagnoses included anemia (iron deficiency), cancer (complex group of diseases) and malnutrition (when the body lacks a variety of needed nutrients), Multidrug-Resistant Organism (a germ that is resistant to many antibiotics), Human Immunodeficiency Virus (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 observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Residents #107 and #125) reviewed for infection control.The facility failed to ensure MA NN disinfected the blood pressure cuff between blood pressure checks for Residents #107 and #125 during medication administration.These failures placed residents at risk of cross contamination and the spread of infection.Findings included: 1. Record review of Resident #107's Comprehensive MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE]. The resident's cognition was severely impaired with a BIMs of 6, and she had a diagnosis of hypertension (high blood pressure).Record review of Resident #107's care plan dated 09/29/25 reflected: Problem:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Residents #2, #3, and #4) of 3 residents reviewed for pressure ulcers.1. The facility failed to provide wound care to Resident#2's Unstageable wound of the left heel, on 01/17/2026 and 01/18/2026.1a. The facility failed to provide wound care to Resident #2's stage 4 pressure wound of the left medial first toe and the left fourth toe on 01/17/2026, 01/23/2026, 01/24/2026, 01/30/2025 and 01/31/2026. 1b. The facility failed to provide wound care to Resident #2's stage 4 pressure wound of the left fourth toe, the left distal medial foot and the left medial first toe on 02/01/2026, 02/07/2026, 02/08/2026 and 02/10/2026.1c. The facility failed to provide wound care to Resident # 2's stageable 4 pressure wounds of the left medial…

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 reviews and interviews, the facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment immediately, but no later than 2 hours after the allegation is made for 1 (Resident #1) of 5 residents reviewed for neglect.The facility failed to notify HHSC when Resident #1 was discovered to have been left in a transport van for several hours in the cold. This failure could place residents at risk of neglectful behavior not being investigated.Findings Include:Record review Resident #1's quarterly MDS assessment, dated 01/29/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney failure requiring dialysis, dementia, and paranoid schizophrenia. Resident #1's BIMS score was 6, indicating he had severe cognitive impairment. His Behaviors assessment did not indicate he did not wander. Resident #1's Functional Ability assessment indicated he used a wheelchair for mobility and required assistance with his ADLs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for one of two incidents reviewed for reporting.The facility failed to report an allegation of neglect when Resident #1 alleged that her leg had been broken during a transfer from her bed to the wheelchair on 12/23/25 due to the facility staff not using a mechanical lift.This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female resident whose most recent admission entry was on 04/10/25. Resident #1 had a BIMS of 10 which indicated she had moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, exploitation, and mistreatment, including injuries of unknown source were thoroughly investigated for one (Resident #1) of 3 residents reviewed for neglect.The facility failed to thoroughly investigate an allegation of neglect when Resident #1 alleged that she sustained a fractured left femur (the bone of the thigh) during a transfer in which staff did not use a mechanical lift as care planned.This failure could place residents at risk of abuse and neglect.Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female resident whose most recent admission entry was on 04/10/25. Resident #1 had a BIMS of 10 which indicated she had moderately impaired cognition. The residents' diagnoses included stroke, end stage renal disease, and there was no diagnosis of dementia or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 2 of 5 residents (Residents #5 and #6) reviewed for ADL care. The facility failed to ensure Residents #5 and #6 were provided with timely incontinence care.This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included:Record review of Resident #5's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure when blood vessels are consistently too high) and hemiplegia/hemiparesis (paralysis on one side of the body/partial weakness on one side). The resident had severe cognitive impairment with a BIMS score of 7. The resident required substantial to maximal assistance 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 observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 5 residents (Residents #5 and #6) observed for infection control. CNA D failed to perform hand hygiene and change gloves while providing Residents #5 and #6 with incontinence care. This failure could affect the residents by placing them at risk for worsening conditions and cross-contamination. Findings included:Record review of Resident #5's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Hypertension (high blood pressure when blood vessels is consistently too high) Hemiplegia or Hemiparesis (hemiplegia paralysis on one side of the body while hemiparesis indicates partial weakness on one side). BIMS score of 7 indicating severe cognitive impairment. Her Functional Status revealed she required substantial/maximal assistance 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 and record review, the facility failed to ensure a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #1. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included:Record review of Resident #1's Discharge MDS assessment, dated 09/11/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and discharged on 09/11/25 to Nursing Home.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 2 of 2 residents (Residents #3 and #4) reviewed for ADL care. The facility failed to provide incontinence care to Residents #3 and #4 every 2 hours and as needed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident #3's quarterly MDS assessment, dated 05/22/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had a diagnosis of Malignant neoplasm of brain, unspecified (cancerous brain tumors where the specific location within the brain has not been determined). He had a BIMS score of 00, which indicated his cognition was severely impaired. The MDS reflected the 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 interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #2) reviewed for pressure ulcer treatment. The facility failed to ensure Resident #2 received wound care according to physician orders. This failure could place the resident at risk of worsening wounds. Findings included: Record review of Resident #2's face sheet, dated 06/18/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 04/02/25. Record review of Resident #2's admission MDS assessment, dated 02/23/25, reflected her diagnoses included metabolic encephalopathy (brain disorder), Pressure ulcer of sacral region, stage 4, Unspecified severe protein-calorie malnutrition, Osteomyelitis of vertebra, sacral and sacrococcygeal region (a bone infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #100) reviewed for enteral nutrition. The facility failed to follow Resident #100's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health. Findings included: Record review of Resident #100's face sheet dated 06/19/25 reflected the resident was [AGE] year-old male admitted on [DATE]. Record review of Resident #100's Quarterly MDS dated [DATE] reflected the resident had severe cognitive impairment with a BIMS score of 00. Resident #100 required supervision or touching assistance with eating. The assessment reflected Resident #100's diagnosis included Anemia (lack of healthy red blood cells), Diabetes Mellitus (high blood sugar), Alzheimer's Disease (gradual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 2 residents (Residents #3 and #4) observed for infection control. 1. CNA I, CNA JJ and CNA KK failed to perform hand hygiene while providing incontinence care to Resident #3 and #4. 2. The facility failed to ensure RN X performed hand hygiene and changed gloves during wound care for Resident #4. This failure could affect the residents by placing them at risk for worsening conditions and cross contamination. Findings included: Record review of Resident #3's quarterly MDS assessment, dated 05/22/25, reflected the resident was a [AGE] year-old male who was admitted to facility the on 02/18/25 and readmitted on [DATE]. Resident #3 had a diagnosis of Malignant neoplasm of brain, unspecified (cancerous brain tumors where the specific location within the brain has not been determined). He had a BIMS score of 00, which indicated his…

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 residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for four (Residents #1, #2, #3 and #4) of four residents reviewed for physician services. The facility failed to ensure Residents #1, #2, #3 and #4 were seen by their attending physician at least once every 60 days. The attending physician's extender was completing all visits for the residents, not alternating visits with the physician. The failure could place residents at an increased risk of not receiving appropriate and adequate medical care and a lack of oversight by the physician, which could place the residents at risk of harm and health decline. Findings included: 1. Record review of Resident #1's face sheet dated 03/26/25 reflected the resident was a [AGE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #3) of four residents reviewed for pharmacy services. The facility failed to administer Resident #3, who had a diagnosis of dementia, with her morning medications on 03/26/25 and 03/27/25. Both the medication aide and nurse acknowledged they were busy and did not attempt to give them to her again after one refusal. As a result, Resident #3 missed eight different medications both days, including blood pressure readings related to blood pressure medication, as well as two supplements. The failure could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort. Findings included: Record review of Resident #3's face sheet dated 03/26/25 reflected the resident was an [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident's drug regimen must be free from unnecessary drugs, without adequate indications for its use for two (Residents #1 and #2) of four residents reviewed for psychotropic medications. The facility failed to ensure Residents #1 and #2 were not prescribed Austedo (a prescription medicine used to treat involuntary movements in adults with tardive dyskinesia (movement disorder characterized by involuntary movements) or Huntington's disease (an illness that causes nerve cells in the brain to decay over time and affects a person's movement, thinking ability, mental health) without adequate indications for its use. The failure could affect residents by placing them at risk for possible adverse side effects, a decreased quality of life and continued use of possible unnecessary medications. Findings included: 1. Record review of Resident #1's face sheet dated 03/26/25 reflected the resident was a [AGE] year-old female who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for one (Resident #1) five reviewed for resident call system, in that: Resident #1's call lights was on the floor and not within reach on 03/24/2025. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of Resident #1's electronic face sheet printed on 03/08/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's (a brain disorder that slowly destroys memory and thinking skills) and esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach. This can cause pain, difficulty in swallowing or chest pain.) Record review of the annual MDS dated [DATE] did not indicate a BIMS score. Section GG…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident has a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of five residents (Resident #1) reviewed for care plans. The facility failed to follow Resident #1's care plan intervention of lowering the bed and the use of half bedrails due to fall risk. This failure could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing. Findings included: Record review of Resident #1's electronic face sheet printed on 03/08/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included but not limited to Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) and esophagitis (inflammation or irritation of esophagus, the pipe that carries food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who were unable to carry out activities of daily living received the necessary services to maintain good nutrition for one of three residents (Resident #1) reviewed for ADLs in that: The facility failed to ensure Resident #1 was provided with feeding assistance. This failure could place residents at risk of not receiving care and services to meet their needs which could result in nutritional needs not being met and a diminished quality of life. Findings included: Record review of Resident #1's electronic face sheet printed 03/08/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) and esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach. This can cause pain, difficulty in swallowing or chest pain.)…

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 residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of five residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the ADON from taking two morphine pills prescribed for Resident #1 on 02/24/25. This failure could place residents at risk of pain and failure to achieve therapeutic effects intended by the physician. The noncompliance was identified as past noncompliance that began on 02/24/25 and ended on 02/24/25. The facility had corrected the noncompliance before the surveyor entered. No Plan of Correction required. Findings included: Record review of Resident #1's undated Face Sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included lung cancer, brain cancer, and high blood pressure. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure residents were free of any significant medication errors for one of six residents (Resident #2) reviewed for pharmacy services. The facility failed to administer Resident #2's cancer medication, Ibrance, as prescribed, which resulted in the resident missing four doses between 08/26/24 and 08/29/24. This failure could place residents at risk of not achieving the therapeutic effects intended by the physician. Findings included: Record review of Resident #2's undated Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure, swelling of the legs, and breast cancer in 2019. Record review of resident #2's quarterly MDS, dated 01/24//25, reflected a BIMS score of 8 indicating she mildly cognitively impaired. Her Functional Status indicated she required staff assistance with her ADLs. Record review of Resident #2's care plan, dated 02/18/25, reflected she had anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 3 of 8 residents (Residents #23, #55 and #81) reviewed for ADL care. 1. The facility failed to ensure Residents #23 and #55 received grooming assistance to remove unwanted facial hair. 2. The facility failed to ensure staff provided consistent showers/baths for Resident #81. These failures could place residents at risk of not receiving hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings included: 1. Record review of Resident #23's Quarterly MDS assessment, dated 11/09/24, reflected the resident was an [AGE] year-old-female who initially admitted on [DATE] and readmitted on [DATE]. The resident had diagnoses of anemia (condition in which the blood doesn't have enough health red blood cells and hemoglobin to carry oxygen through the body), heart failure,…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 2 kitchens (North kitchen and South kitchen) reviewed for food and nutrition services. 1. The facility failed to ensure food items were labeled and dated with name of product, date opened, and use by date. 2. Nutrition Aide M failed to wear a beard guard while prepping drinks for the lunch meal on 12/10/24. 3. Nutrition Aide L failed to wear a beard guard while putting away clean dishes on 12/10/24. These failures could place residents at risk for food borne illness. Findings included: 1. Observation on 12/08/24 at 9:16 AM of the facility's North Building kitchen revealed the following: -cooked chicken and rice soup in a plastic container was not labeled and did not have a prepared date or use by date. -cheese in a plastic container was not labeled and did not have a prepared date or use by date. -sautéed mushrooms in a plastic container was not labeled and did not have a prepared date or use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had a right to be treated with respect and dignity for 1 of 3 residents (Resident #189) reviewed for dignity. The facility failed to ensure Resident #189's catheter urine collection bag had a privacy cover. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #189's face Sheet, dated 12/11/24, reflected the resident was a [AGE] year-old male who was admitted on [DATE]. Review of Resident #189's MDS dated [DATE] reflected the resident's cognition was moderately impaired with a BIMS score of 07. Active diagnosis included Indwelling catheter (including suprapubic catheter and nephrostomy tube), ostomy, cancer, hypertension, benign prostatic hyperplasia, renal insufficiency, obstructive uropathy, diabetes mellitus, fractures, and stroke. Section GG reflected resident required partial/moderate assistance 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 and interview, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 35 residents (Resident #55) reviewed for call light access. The facility failed to ensure Resident #55 had access to her call light. This failure could place residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #55's undated Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included legal blindness, muscle wasting, and difficulty swallowing. Record review of Resident #55's quarterly MDS assessment, dated 11/06/24, reflected a BIMS score was not completed due to her medical conditions. Her Functional Status assessment reflected she required substantial assistance with all of her ADLs. Record review of Resident #55's care plan, dated 09/24/24, reflected she had a self-care deficit and required assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 1 resident (Resident #133) reviewed for wound care. The facility failed to ensure the diabetic wound on Resident #133's left upper side second toe was covered with a dressing. This failure could place residents at risk of pain and lead to systemic infections causing harm for residents. Findings included: Review of Resident #133's face sheet dated 12/10/24 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Review of Resident #133's quarterly MDS assessment dated [DATE], reflected Resident #133 had diagnoses which included diabetes (high blood sugar). Had a BIMS score of 03, reflecting the resident's cognition was severely impaired. He was at risk of diabetic foot ulcers. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Residents #189) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #189's catheter urine collection bag was kept off the floor. This failure placed residents at risk of urinary tract infection. Findings included: Record review of Resident #189's face Sheet, dated 12/11/24, reflected the resident was a [AGE] year-old male who was admitted on [DATE]. Record review of Resident #189's MDS dated [DATE] reflected the resident's cognition was moderately impaired with a BIMS score of 07. Active diagnosis included Indwelling catheter (including suprapubic catheter and nephrostomy tube), ostomy, cancer, hypertension, benign prostatic hyperplasia, renal insufficiency, obstructive uropathy, diabetes mellitus, fractures, 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, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of five resident (Resident #81) reviewed for nutrition. The facility failed to ensure Resident #81 maintained acceptable parameters of nutritional status and provide timely interventions as demonstrated by Resident #81 experiencing a 15.51% weight loss in 30 days from October to November. Resident #81 had not continued to lose weight from November to December, however. This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization. Findings included: Review of Resident #81's face sheet, dated 12/10/24, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #81's admission MDS Assessment, dated 10/03/24, reflected she did not have a BIMS score calculated (a term used to screen and identify a resident's cognition) Her active diagnoses included stroke…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored securely for 2 (Resident #177 and Resident #189) of 18 residents and for 1 (100 Back Hall cart) of 8 carts reviewed for secure medication storage. 1. RN-F failed to secure his medication cart. 2. Resident #177 had 1 new box of arthritis pain cream stored at the resident's bedside table not locked in a lock box or secured in the medication cart or medication room. 3. Resident #189 had a tube of arthritis pain cream, zinc oxide cream, and eye drops inside his nightstand table not locked in a lock box or secured in the mediation cart or mediation room. These failures could place residents at risk of accessing medications not prescribed for them, and at risk of overmedicating or adverse drug reactions. Findings included: 1.Observation and interview on 12/08/24 at 11:15 AM revealed the nurse medication cart for the 100 Hall was unsecured, the locking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was prepared and served according to the resident's assessment, plan of care, and in a form designed to meet the resident's needs for 1 (lunch on 12/10/24) of 3 meals reviewed for resident's needs. The facility failed to follow Resident #29's physician's order for pureed consistency food and nectar thickened liquids for the lunch meal on 12/10/24. This failure could place residents at risk of decreased food intake, weight loss and an increased risk of aspiration. Findings include: Review of Resident #29's face sheet, dated 12/11/24, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #29's Quarterly MDS Assessment, dated 10/31/24, reflected he had a BIMS score of 05, indicating severe cognitive impairment. His diagnoses included pneumonia (an infection that inflames the air sacs in one or both lungs), Cerebrovascular Accident (CVA), Transient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area and to ensure call light cord was accessible for 1 of 35 residents (Resident #130) reviewed for call light access. The facility did not adequately equip Resident #130's room with a call light cord to allow the resident to call for assistance. This failure could place residents at risk of not being able to call for assistance when needed. Findings included: Review of Resident #130's Face sheet, dated 12/10/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #130's quarterly MDS assessment, dated 10/27/24, reflected he had diagnoses of hypertension (high blood pressure) and hemiplegia (paralysis on one side of the body) and hemiparesis (one-side muscle weakness). His brief interview for mental status assessment 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, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and home-like environment for 1 of 5 residents (Resident #1) reviewed for environment. The facility failed to ensure Resident #1's bed was made in a timely manner after being sanitized, which prevent the resident from being able to lie in bed. These failures could place residents at risk of an unsafe or uncomfortable environment. Findings included: Record review of Resident #1's face sheet dated 09/18/24 reflected the resident was an [AGE] year-old female admitted on [DATE] with diagnoses including dementia (general decline in cognitive ability), history of falling, muscle weakness, lack of coordination, hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was usually understood and understood others. The MDS indicated a BIMS score of 05 indicating Resident #1 was severely cognitively impaired. The MDS…

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

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Medication Cart #1) of three medication carts reviewed. MA B failed to ensure Medication Cart #1 was locked when unattended on 08/27/24. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: In an observation on 08/27/24 at 10:23 AM, Medication Cart #1 was observed unlocked and unattended near the one of the main entrances of the facility. There were two staff members at the nurses' station but walked away after a couple of minutes. There were four residents in wheelchairs in the immediate area. Another resident wheeled himself into the building from outside while the cart was unlocked and unattended. LVN A was observed coming from an office area behind the nurses' station. The office did not have any windows. LVN A stated Medication Cart #1 belonged to MA B. He stated she was down the hall, 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, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for six (Residents #2, #3, #4 #5 #6 and #7) of six residents reviewed for safe clean homelike environment. 1. The facility failed to ensure Residents #2, and #3 did not have soiled briefs in the trash cans in their rooms. 2. The facility failed to ensure Residents #2, #4, and #5 had clean privacy curtains in their rooms. 3. The facility failed to ensure the ceiling vents Resident #5, #6 and #7's rooms were clean. These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment. Findings included: 1. Review of Resident #2's Face Sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral ischemia (common mechanism of acute brain injury that results from impaired blood flow to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 6 (Residents #1, #2, #8, #9, #10, #13 ) of 6 residents reviewed for ADL care. The facility failed to provide incontinence care to Residents #1, #2, #8, #9, #10, #13 every 2 hours and as needed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1. Review of Resident #2's Face Sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral ischemic (common mechanism of acute brain injury that results from impaired blood flow to the brain). Record review of Resident #2's Care Plan dated 02/16 /24, reflected the following: Goal: Resident will be assisted with incontinence to ensure social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident #2 and #5) of 2 residents reviewed for pressure ulcer treatment. The facility failed to ensure Resident #2 and #5 received wound care according to physician orders. This failure could place the resident at risk of worsening wounds. Findings included: 1. Review of Resident #5's face sheet, dated 04/18/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). Review of Resident #5's MDS assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 6 residents (Residents #1 and #2) reviewed for ADLs. The facility failed to ensure Resident #1 and Resident #2 received showers as scheduled for the month of December 2023, January 2024, and February 2024. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: 1. Review of Resident #1's face sheet, dated 02/23/24, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body), muscle wasting and atrophy, Type 2 diabetes mellitus, muscle weakness, other lack 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 observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one of three residents (Resident #3) reviewed for oxygen. The facility failed to ensure Resident #3's oxygen concentrator and nasal cannula was dated, labeled, and changed on a weekly basis. The facility failed to ensure Resident #3's oxygen delivered as ordered by physician at 2 liters per minute. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection. Findings included: Review of Resident #3's admission Record dated 02/23/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included low back pain, Hypoxemia (an abnormally low level of oxygen in the blood), chronic pain due to trauma, elevated blood-pressure reading with diagnosis of high blood pressure, anemia…

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 resident's representative was notified when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The RP/family was not notified when of Resident #1 who was not capable of making decisions was discovered with a new wound on 09/22/23 denying the RP/family the opportunity to participate in the resident's treatment options. This failure could place residents at risk of not having the RP/family aware, informed of and/or participating in treatment options. Findings included: Review of Resident #1's closed clinical records revealed a quarterly MDS assessment dated [DATE]. The MDS assessment reflected the resident was a [AGE] year-old female admitted to the facility 07/05/23. Diagnoses included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life),…

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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for wound assessments. Resident #1's wound to the right finger was not assessed until four days after discovery on 10/26/23. This failure placed residents at risk for delays in treatment, developing infections and unidentified deterioration of their wounds. Findings included: Review of Resident #1's closed clinical records revealed a quarterly MDS assessment dated [DATE]. The MDS assessment reflected the resident was a [AGE] year-old female admitted to the facility 07/05/23. Diagnoses included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertensive heart disease heart problems that occur because of high blood pressure), 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, interview, and record review, the facility failed to ensure residents had the right to self-determination for 2 of 7 residents (Residents #55, and #173) reviewed for self-determination in that: 1. CNAs failed to change Resident #55's bed linen, leaving her with no bed sheets. 2. Dietary staff were rude in their interactions with Resident #173 when discussing her food choices. These failures could place residents at risk of decreased feelings of self-worth. Findings included: Review of Resident #55's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke, speech impairment, seizures, and obesity. Review of Resident # 55's quarterly MDS assessment, dated 08/21/23, revealed a BIMS score of 8, indicating she was moderately cognitively impaired. Her Functional Status indicated she required extensive assistance with most of her ADLs. Review of Resident #55's care plan, dated 10/25/23, revealed she had 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 observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 3 of 5 residents (Residents #503, #161, and #60) reviewed for environment. 1. The facility failed to ensure Residents #503's bed curtain was free from a dried brown substance. 2. The facility failed to ensure the large hole in Resident #161's and #60's bedroom wall was repaired. These failures could affect any resident and place them at risk for not having a safe and sanitary homelike environment. Findings included: 1. Review of Resident #503's undated admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, acute congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Review of Resident #503's quarterly MDS, dated [DATE], revealed a BIMS score of 11 indicating moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received proper treatment and assist the resident in making appointments for 1 of 1 resident (Resident #116) whose records were reviewed for vision services in that: Nursing staff failed to ensure that Resident #116 was scheduled for an ophthalmologist appointment since July 2023. This failure could affect residents and contribute to a decline in vision. Findings included: Review of Resident #116's face sheet, dated 11/08/23, revealed the resident was initially admitted to the facility on [DATE] with diagnoses to include cerebral infarction and chronic diastolic congestive heart failure. Review of Resident #116's Consolidated Order dated 10/21/23 revealed Resident #116 had a diagnosis of Unspecified Glaucoma. Review of Resident #1's quarterly MDS, dated [DATE], revealed the resident had severe cognitive impairment with a BIMS score of 6. Review of Resident #1's nurse's note, dated 07/19/23, reflected in part: Called [name 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 observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for 1 of 36 residents (Resident #146) reviewed for foot care. The facility did not ensure Resident #146 received toenail care. This failure could place residents at risk for not receiving foot care which is consistent with professional standards of practice. Findings included: Record review of the face sheet, dated 11/08/23, revealed Resident #146 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of secondary hypertension (high blood pressure), cerebral infarction (disrupted blood flow to the brain), central pain syndrome. Record review of Resident #146's MDS, dated [DATE], revealed resident BIMS score was 00, indicative of severe cognitive impairment. The MDS revealed Resident #146 had no behaviors or rejection of care. The MDS revealed Resident #146 required substantial/maximal assistance when putting on/taking off…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 5 residents (Resident #113) reviewed with limited range of motion. The facility failed to ensure Resident #113 was receiving contracture management to treat their contracted hands. This failure could place residents at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings included: Review of Resident #113's face sheet, dated 11/08/23, revealed the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute kidney failure, severe sepsis (a life-threatening condition that occurs when an infection triggers a massive inflammatory response in the body, damaging vital organs), and diabetes. Review of Resident #113's physician's orders, dated 11/08/23, reflected the following: Frequent visual checks every shift…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #153 and #250) of 11 residents reviewed for accidents. 1. The facility failed to ensure Resident #153, who resided in the secure unit, did not have access to a razor. 2. The facility failed to have a fall mat in place, while in bed, for Resident #250. These failures could place residents at risk for decline in health, and decreased quality of life. Findings included: 1. Review of Resident #153's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included non-Alzheimer's dementia and bipolar disorder . The MDS further reflected Resident #153 had a BIMS score of 6 (cognition severely impaired). The resident also required extensive assistance of two staff for personal hygiene. Review of Resident #153's care plan updated on 11/06/23 indicated 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 and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents to include providing pharmaceutical services including procedures that assure the accurate acquiring of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Resident #300) reviewed for medication administration. The facility failed to administer medication, Xtandi, to Resident #300 from 10/27/23- 11/08/23. This failure placed resident at risk of preventable pain and worsening of their medical conditions. Findings included: Review of Resident #300's undated face sheet revealed the resident was a [AGE] year-old male admitted to facility on 10/27/23 with a history of malignant neoplasm of prostate (prostate cancer). Review of Resident #300's MDS, dated [DATE], revealed a BIMS score of 12, indicating resident had moderate cognitive impairment. His functional status indicated he required the assistance of one person for all ADLs. Review of Resident #300's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one (Resident #300) of 6 residents reviewed for medication errors was free of significant medication errors. The facility failed to obtain Xtandi (medication used in treatment of cancer) and administer medication per Physician Order. This failure placed the resident at risk of complications due to possible cancer spread. Findings included: Review of Resident #300's undated face sheet revealed the resident was a [AGE] year-old male admitted to facility on 10/27/23 with a history of malignant neoplasm of prostate (prostate cancer). Review of Resident #300's MDS, dated [DATE], revealed a BIMS score of 12, indicating resident had moderate cognitive impairment. His functional status indicated he required the assistance of one person for all ADLs. Review of Resident #300's Physician Order dated 10/27/2023-11/07/2023 revealed an order dated 10/27/2023 for Xtandi (Enzalutamide, sold under the brand name Xtandi, is a nonsteroidal antiandrogen 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 and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #113) reviewed for clinical records. The facility failed to ensure staff accurately documented on Resident #113's MAR on 11/07/23. This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #113's face sheet, dated 11/08/23, revealed th resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute kidney failure, severe sepsis (a life-threatening condition that occurs when an infection triggers a massive inflammatory response in the body, damaging vital organs), and diabetes. Review of Resident #113's physician's orders, dated 11/08/23, reflected the following: Frequent visual checks every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately for 1 of 3 residents (Resident #1) reviewed for abuse reporting. The facility failed to ensure LVN A reported an allegation of sexual abuse involving Resident #1. This failure could place residents at risk for not having allegations of abuse reported. Findings included: 1. Review of Resident #1's face sheet, dated 11/07/23, reflected the resident was a [AGE] year-old female. Her diagnoses included a sexually transmitted disease and dementia. Review of Resident #1's MDS assessment, dated 09/07/23, reflected she admitted to the facility on [DATE]. The resident's cognitive status was moderately impaired. She had no behaviors. Her diagnoses included traumatic brain dysfunction and depression. Review of Resident #1's Care Plan, dated 10/25/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one (Resident #1) of five residents reviewed for resident rights. The facility failed to ensure Dietary Aide B treated Resident #1 with respect and dignity in her interaction with him on 09/15/23 to which Resident #2 was a witness to. This failure led to the residents having feelings of being worried or scared. Findings included: Review of Resident #1's face sheet, dated 10/12/23, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 10/03/23. His diagnoses included chronic obstructive pulmonary disease (a persistent respiratory symptoms like progressive breathlessness and cough) and morbid obesity. Review of Resident #1's significant change in status MDS Assessment, dated 08/28/23, reflected he had a BIMS of 07, indicating moderate cognitive impairment. Review of Resident #2's face sheet, dated 10/12/23, reflected the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of five residents (Resident #3) reviewed for ADL care. The facility failed to ensure Resident #3 received timely incontinent care. This failure could put residents at risk of impaired skin integrity and decreased feelings of self-worth and dignity. Findings included: Review of Resident #3's face sheet, dated 10/12/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included generalized anxiety disorder and muscle weakness. Review of Resident #3's quarterly MDS Assessment, dated 09/13/23, reflected she had a BIMS of 08 indicating moderate cognitive impairment. Further review revealed she required assistance with personal hygiene and toilet use as extensive assistance with one person physical assistance.…

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.