Westpark Rehabilitation and Living

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 the facility's for one of one kitchen reviewed for food and nutrition services. The Dietary Manager failed to wear a beard cover in the kitchen while prepared food was present.The facility failed to ensure dietary staff properly labeled and dated stored food received by vendors.The facility failed to ensure stored food in the freezer was concealed from air-borne contaminants.The facility failed to ensure the tea dispenser was covered. The facility failed to ensure the following were thoroughly cleaned and/or sanitized: ice machine and ice scoop in the kitchen, sugar and flour bins, the serving table, serving table had a sanitizer container (red bucket) for sanitization, the dining room ice dispenser, the dining room counter and sink, and the ice chest on the 300-hall.These failures could place residents at risk of exposure to food contamination and illness. Findings included:Observations on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 three (Residents #10, #150 and #60) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA K wore a gown while changing Resident #10's linen, who was on enhanced barrier precautions due to having a g-tube, on 02/03/2026. 2. The facility failed to ensure RN E wore a gown when disconnecting Resident #150's antibiotic via PICC line, who was on enhanced barrier protection, on 02/05/2026.3. The facility failed to ensure MA G removed her gloves and performed hand hygiene between checking Resident #60's blood pressure and using the laptop on her medication cart on 02/04/2026. These failures could place residents at risk of cross-contamination and development and spread 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 observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for two direct care staff (RN D and MA G) and one (Crash Cart) of four carts reviewed for other environmental conditions.1. The facility failed to ensure that the drawers of the crash cart was not easily opened when not in use on 02/05/2026.2. The facility failed to ensure that RN D did not leave a container of germicidal wipes on top of the treatment cart at the wander unit unattended on 02/05/2026. 3. The facility failed to ensure MA G did not leave a container of germicidal wipes on top of her cart unattended on 02/05/2026.These failures could prevent the residents from having an environment that was safe for the residents, staff, and public. Findings include:1. An observation on 02/05/2026 at 8:15 AM revealed a crash cart was parked at the entry of hall 100. The drawers of the crash cart was not secured and could easily be opened.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #6) of fourteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #6's room was in a position that was accessible to the resident on 02/04/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #6's Face Sheet, dated 02/04/2026, reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. The resident was diagnosed with cerebral palsy (affects body movement and muscle coordination due to brain injury or malformation). Record review of Resident #6's Comprehensive MDS Assessment (tool used to measure health status), dated 11/20/2025, reflected intact cognition with a BIMS (tool…

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 notify the State Mental Health Authority to inform them of a significant change in mental condition for two (Residents #2 and #3) of eight residents reviewed for Preadmissions Screening and Annual Resident Review (PASRR).1. The facility failed to notify the SMHA to ensure Resident #2 received a new PASRR level 1 screening following identification of his diagnosis of major depressive disorder on 06/20/2017, delusional disorder on 04/15/2021, and dementia on 01/08/2023.2. The facility failed to notify the SMHA to ensure Resident #3 received a new PASRR level 1 screening following identification of his diagnoses of bipolar disorder, major depressive disorder, and generalized anxiety disorder on 11/14/2023.These failures could place the residents at risk of not receiving the care and services they need in the most appropriate setting, when a significant change in their status occurs.Findings included:1. Review of Resident #2's Face Sheet, dated 02/05/2026,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 12 residents (Resident #22 and #36 ) reviewed for care plan. The facility failed to ensure Resident #22's care plan reflected a plan of care for the cancer lesion on her forehead. The facility failed to ensure Resident #36's Comprehensive Care Plan reflected the resident had a midline intravenous catheter for antibiotic administration.These failures could place residents at risk of their needs not being met. Findings included:Record review of Resident #22's Face Sheet, dated 02/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had paralysis on the left side of her…

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 who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #114) reviewed for ADL care. The facility failed to ensure Resident #114 received any scheduled showers for January 2026 and no indication of refusal. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings included: Record review of Resident #114's Face Sheet, dated 02/05/26, reflected a 48 -year-old male who was admitted to the facility on [DATE]. Resident #114 had a diagnosis of morbid obesity. Record review of Resident #114's MDS Assessment, dated 11/25/25, reflected the resident's BIM (12) indicated a moderate cognitive impairment. The MDS Assessment reflected the resident had active diagnoses of morbid obesity 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 that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Resident #114) reviewed for hazards. The facility failed to ensure Resident #114 did not have a bottle of rubbing alcohol in his room on 02/04/26.This failure could prevent the residents from having an environment that was free from hazards. Findings include:Record review of Resident #114's Face Sheet, dated 02/05/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #114 had a diagnosis of major depressive disorder. Record review of Resident #114's MDS Assessment, dated 11/25/25, reflected the resident's BIM (12) indicated a moderate cognitive impairment. The MDS Assessment reflected the resident had an active diagnosis of schizophrenia.In an observation on 02/04/2026 at 10:43 AM, Resident #114 was observed with a bottle of rubbing alcohol on his bedside table.During an interview on 02/04/26 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for two (Resident #16 and Resident #32) of sixteen residents and one (Nurse's Cart) of two carts reviewed for pharmaceutical services. 1. The facility failed to dispose of an over-the-counter gas relief dated 12/2025.2. The facility failed to dispose of Resident #16's expired Linzess capsules dated 12/2025.3. The facility failed to dispose of Resident #32's expired Clonidine tablets with discard after date of 04/30/2024.These failures could place residents at risk of not receiving the medication's full therapeutic benefits and possible adverse reactions when taken. Findings included:An observation of the nurse's cart on 02/06/2026 at 10:52 AM, revealed the following:-Linzess capsules for Resident #16 with an expiration date of 12/2025, -Clonidine tablets for Resident #32 with a discard after date of 04/30/2024, and -Gas Relief…

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 follow policies and procedures to ensure that each resident or the resident's representative had the opportunity to refuse immunization for 1 of 6 residents (Resident #33) reviewed for vaccinations. The facility failed to ensure Resident #33 did not receive the influenza vaccination on 10/17/25. This failure could place residents at risk of having an adverse reaction and suffering harm.Findings included: Record review of Resident #33's Face Sheet, dated 02/05/26, reflected a [AGE] year-old female admitted [DATE]. Resident #33 had diagnoses of dementia (cognitive decline) and anemia (low red blood cells). Record review of Resident #33's Quarterly MDS Assessment, dated 11/20/25, reflected the resident's BIM (3) indicated a severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnosis of dementia. Record review of Resident #33's Immunization detail regarding the Influenza Vaccine, dated 10/17/25,…

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, interviews, and record review, the facility failed to develop a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured for one of three residents (Resident #2) reviewed for Care Plans. The facility failed to ensure Resident #2's usage of a Nebulizer device was care planned. This failure could place the resident at risk of not receiving the necessary care and services required. Findings include: Record review of Resident #2's Face Sheet, dated 09/243/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included quadriplegia (paralysis). Record review of Resident #2's Quarterly MDS assessment, dated 7/28/25, reflected he had a BIMS score of 14 (intact cognitive response). For ADL care, it reflected the resident required total assistance. Record Review of Resident #2's Physician Orders, dated 9/24/25, reflected Ipratropium -Albuterol Solution 0.5-2.3 MG/ML 3 ml inhale orally every 4 hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure each resident is being watched and has assistance devices, when needed, to prevent accidents for one (Resident #1) of five residents reviewed for accident prevention. The facility failed to ensure Residents #1 had physician orders for the scoop mattress on his bed. The facility failed to ensure Resident #1's fall mat was properly positioned while he was in bed. These failures could prevent the resident from having an environment that was free and clear of accidents and hazards. Findings include: Record review of Resident #1's Face Sheet, dated 09/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #1's Quarterly MDS assessment, dated 8/20/25, reflected he had a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance and an active diagnosis 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 observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's nebulizer mask was properly stored in a bag when not in use on 09/24/25. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #2's Face Sheet, dated 09/24/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included quadriplegia (paralysis). Record review of Resident #2's Quarterly MDS assessment, dated 7/28/25, reflected he had a BIMS score of 14 (intact cognitive response). For ADL care, it reflected the resident required total assistance. There was no…

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 reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two of ten residents (Resident #1 and Resident #2) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #1's room was in a position that was accessible to the resident on 08/21/2025.2. The facility failed to ensure the call light system in Resident #2's room was in a position that was accessible to the resident on 08/21/2025.These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #1's Face Sheet, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which…

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, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (treatment cart #1) of 1 treatment carts reviewed for storage of medications. The facility failed to ensure treatment cart #1 was locked while unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: An observation on 04/01/25 at 2:36 PM revealed, treatment cart #1 was unlocked and unattended. All drawers could be opened and supplies (bandages, gauze, scissors, etc) could be easily accessed. 1 resident in a wheelchair was observed within approximately 5 feet from the treatment cart. In an interview and observation on 04/01/25 at 2:40 PM, with DON revealed that treatment cart #1 was unlocked and all drawers were able to be opened with supplies easily accessible. The DON stated that staff member had just stepped away. The DON stated her expectation was when the treatment cart was not in use that the treatment cart was locked. The DON stated…

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 two (Residents #1 and #2) of eight residents reviewed for medications and pharmacy services. 1. The facility failed to obtain hospital discharge orders and administer Resident #1's seizure medication after his admission to the facility on Friday-03/21/25, resulting in him missing the medication on the evening of 03/21/25 and the morning of 03/22/25. 2. The facility failed to administer Resident #2's long and short acting inhalers related to her COPD after her admission to the facility on Friday-03/21/25 and on Saturday 03/22/25, in accordance with the admission orders. The failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #3 and Resident #4) of ten residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #3 and Resident #4's rooms were in a position that was accessible to the residents on 02/18/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #3 Record review of Resident #3's Face Sheet, dated 02/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and unsteadiness on feet. Record review of Resident #3's Comprehensive MDS Assessment, dated 01/25/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The resident required…

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 was incontinent of bladder received services and assistance to prevent urinary tract infections for one (Resident #2) of one resident reviewed for Urinary Incontinence. The facility failed to prevent Resident #2's indwelling urinary Foley catheter (device that drains urine from the urinary bladder) device from contact with the floor on 02/18/2025. This failure could place the resident with indwelling urinary catheter devices at risk for the development of urinary tract infections. Findings included: Review of Resident #2's Face Sheet, dated 02/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #2's Quarterly MDS Assessment, dated 12/18/2024, reflected the was unable to complete the interview to determine the BIMS score. 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 that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of five residents reviewed for Respiratory Care. The facility failed to ensure Resident #1's face mask for his nebulizer was properly stored when not in use on 02/18/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #1's Face Sheet, dated 02/18/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's Quarterly MDS Assessment, dated 02/07/2025, reflected the resident was unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 one (Resident #5) of ten residents reviewed for Infection Control. The facility failed to ensure CNA G and COTA G changed their gloves and performed hand hygiene while providing incontinent care to Resident #5 on 02/18/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #5's Face sheet, dated 02/18/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with cerebral palsy (a disorder that affects movement and muscle tone due to brain injury). Record review of Resident #5's Comprehensive MDS Assessment, dated 01/25/2025, reflected the resident was unable to complete…

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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #1) of 5 residents reviewed for Dignity. The facility failed to treat Resident #1 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for her catheter bag. This failure placed residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life. Findings included: Review of Resident #1's Face Sheet, dated 12/28/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with obstructive and reflux uropathy (a blockage in the urinary flow causing the urine to flow back to the kidneys). Review of Resident #1's Quarterly MDS Assessment, dated 11/08/2024, reflected the resident was unable to complete 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 observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 7 (room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7) of 10 resident rooms and the hallway floors reviewed for cleanliness and sanitization. The facility failed to ensure that Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized. The facility failed to ensure that the facility hallway floors were cleaned. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 11/19/24 at 11:14 AM of the facility hallways revealed thick dirt and some reddish stains along the borders of the floor. An observation on 11/19/24 at 11:16 AM of Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black dirt…

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, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of twelve residents (Resident #35, Resident #55 and Resident #45) reviewed for Respiratory Care. 1. The facility failed to ensure Resident #35's nasal cannula for her oxygen concentrator was properly stored. 2. The facility failed to ensure Resident #55's face mask for his nebulizer was properly stored when not in use. 3. The facility failed to ensure Resident #45's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) at the back of the wheelchair was properly stored. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings include: 1. Record review of Resident #35's face sheet, dated 11/21/2024, reflected 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, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure the ice chest, located on the 400-hall, was cleaned. 2. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the stored date. 3. The facility failed to ensure that the sugar and flour bins were cleaned. 4. The facility failed to ensure the ice scoop in the facility kitchen was cleaned. 5. The facility failed to ensure the kitchen cooking equipment was cleaned. 6. The facility failed to ensure the tea dispenser had the top placed back once the tea had brewed. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 11/19/24 from 9:01 AM to 9:13 AM in the facility'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 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 two of eight residents (Resident #6 and Resident #41) reviewed for Infection Control. 1. The facility failed to ensure CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #6 on 11/19/2024. 2. The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #41 on 11/20/2024. 3. The facility failed to ensure CNA C would not place the pericare cleanser that would be used for incontinent care inside her pocket before using it on 11/19/2024. These failures could place residents at risk of cross-contamination and development of infections. Findings include: 1. Record review of Resident #6's face sheet, 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 observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #35) of sixteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure Resident #35 call light was answered within a reasonable time on 11/20/2024. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: During a confidential group interview 6 of 6 residents stated it took the weekday staff 30 minutes-1 hour to respond to the call lights, and the weekend staff 1 hour or more to respond to the call lights. Record review of Resident #35 face sheet dated 11/21/2024 reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: Dementia (condition characterized by loss of brain functions such as memory loss), chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the right to personal privacy which includes accommodations during personal care for one (Resident #1) of fourteen residents reviewed for Privacy. The facility failed to ensure LVN A closed Resident #1's door while checking the resident's blood sugar and while administering insulin on 11/20/2024. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment. Findings included: Review of Resident #1's Face Sheet, dated 11/21/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #1 was diagnosed with type 2 diabetes mellitus (high blood sugar) and unspecified dementia (a condition characterized by loss of memory and ability to reason) with agitation. Review of Resident #1's Quarterly MDS Assessment, dated 11/10/2024, reflected the resident scored 99 on her BIMS Summary Score denoting the resident was unable to complete the interview to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for one (Resident #45) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #45's Quarterly MDS Assessment, dated 11/10/2024, accurately reflected that Resident #45 was on oxygen therapy. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Review of Resident #45's Face Sheet, dated 11/21/2024, revealed the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with respiratory failure with hypoxia (insufficient amount of oxygen in the body). Review of Resident #45's Quarterly MDS Assessment, dated 11/10/2024, reflected the resident scored 99 on her BIMS Summary Score denoting the resident was unable to complete the interview to determine the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 3 residents (Resident #66) reviewed for accident hazards. The facility failed to obtain physician orders or a physician assessment, as of 11/19/24, for Resident #66 for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could place residents at risk of accidents and hazards. Findings included: Record review of Resident #66's face sheet, dated 11/21/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #66 had diagnoses which included seizures, syncope and collapse, and muscle weakness. Record review of Resident #66's Quarterly Minimum Data Set (MDS) assessment dated [DATE], reflected, he had a Brief Interview for Mental Status (BIMS) score of 99. ADL care reflected transfers, toileting, and bathing and the resident was totally dependent for 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 observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of two residents (Resident #6) reviewed for Incontinent Care. The facility failed to ensure CNA C did not use the same wipes used to clean Resident #6's groin (junction between the central part of the body and the thighs) to clean the resident's front part on 11/19/2024. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings include: Record review of Resident #6's face sheet, dated 11/21/2024, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and muscle weakness. Record review of Resident #6's Comprehensive MDS Assessment, dated 08/19/2024,…

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 appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of two resident (Resident #39) reviewed for feeding tube. 1. The facility failed to ensure LVN A used a new syringe during Resident #39's medication administration via g-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) on 11/20/2024. 2. The facility failed to ensure LVN A put on Resident #39's abdominal binder on 11/20/2024 as per order. These failures could place residents at risk of infection and accidental pulling of the gastronomy tube. Findings include: Record review of Resident #39's face sheet, dated 11/21/2024, reflected a [AGE] year-old female who was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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, and mental and psychosocial needs for one (Resident #1) of three residents reviewed for care plans. The facility failed to ensure two staff performed incontinence care per the care plan for Resident #1. This failure could place residents at risk for not receiving care consistent with their care plan. Findings included: Review of Resident #1's MDS quarterly assessment dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She was always incontinent of bladder and bowel. She required the extensive of two staff for incontinence care and bed mobility. Her cognitive status was unable to be determined. Her diagnoses included stroke. Review of Resident #1's Care Plan dated 07/17/20, 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 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 infection for one (Resident #1) of two residents observed for incontinence care. CNA A failed to perform hand hygiene and clean Resident #1's mattress during incontinence care. This failure could place residents at risk for infection during incontinence care. Findings included: Review of Resident #1's MDS quarterly assessment dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She was always incontinent of bladder and bowel. She required the extensive of two staff for incontinence care and bed mobility. Her cognitive status unable to be determined. Her diagnoses included stroke. Review of Resident #1's Care Plans reflected the following: -04/17/23 History of frequent urinary tract…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 10 residents (Residents # 37, #30, #21, #47) reviewed for care plans. The facility failed to address Residents #37, #30, #21 and #47's elected code status on their comprehensive person-centered care plan. This failure could affect residents and could result in resident's needs not being met. Findings included: 1. Review of Resident #37's face sheet, undated, revealed the resident was a [AGE] year-old female admitted [DATE] with a history that included pulmonary hypertension (a condition that affects the blood vessels in the lungs), hypertension (high blood pressure), pleural effusion (the accumulation of fluid in between the parietal and visceral pleura,…

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 safety in the facility's only kitchen. 1. The facility failed to ensure Dietary Aide G's hair restraint was worn properly and the Dietary Manager wore a beard restraint. 2. The facility failed to ensure stove top (range/griddle) and ovens were cleaned in accordance with professional standards. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: Observation on 10/17/23 at 9:20 AM revealed Dietary Manager was not wearing a beard covering (restraint). Observation on 10/17/23 at 9:25 AM revealed Dietary Aide G, who was responsible for dishwashing, was not wearing a hairnet properly in place. Observation and interview on 10/17/23 at 9:28 AM revealed the stove, range, and ovens were layered in grease, food spills, and food particles. The Dietary Manager stated he had received a cleaner in the previous day and planned on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services, which included procedures that assured accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident, for 1 of 16 residents (Resident #15) reviewed for pharmacy services. The facility failed reorder the pain medication oxycodone in time causing Resident #15 to missed three doses on 10/17/23. This failure could place residents at risk for not receiving the therapeutic benefits of the prescribed medications. Findings included: Review of Resident #15's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, muscle weakness, fibromyalgia. The MDS further reflected the resident had clear speech, was understood and understood others. Review of Resident #15's care plan revised on 09/28/23 reflected the resident had complaints of pain related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #1) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility's Pharmacist Consultant recommended Resident #15's Lexapro 10 mg be discontinued. The physician agreed but the medication continued to be administered to the resident. This failure could place residents on psychoactive medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #11's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebrovascular accident, non-Alzheimer's dementia, depression, bipolar disorder, and psychotic disorder. Review of Resident #11's care plan revised on 03/28/23 reflected the resident had potential for mood problem related to…

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

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 one of three residents (Resident #27) reviewed for infection control, in that: 1. RN A failed to perform hand hygiene prior to entering room [ROOM NUMBER] to obtain blood pressure. 2. RN A failed to clean the blood pressure wrist cuff after checking vitals of Resident #27 and then placing the contaminated wrist cuff in the top drawer of the medication cart. 3. RN A prepared medications for Resident #27 by placing the medications in small dose cups and transported the dose cups by pinching the side of the dose cup using a forefinger inserted into dose cup and thumb on the outside of the dose cup. Failure to follow Infection Control policy placed residents at risk of infection/illness. Findings included: Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 2 Medication Carts (400 Hall Medication Cart) reviewed for pharmacy services. The facility failed to ensure 400 Hall Medication Cart did not include medication for a deceased resident, Resident #1. This failure could place residents at risk of not receiving the correct medication, adverse reactions to medications, and worsening of symptoms of diseases. Findings Include: An observation on [DATE] at 7:52 AM, revealed there was medication on the 400 Hall Medication Cart for Resident #1. Record review of Resident #1's electronic record revealed the resident passed away on [DATE]. The status noted on her electronic record was, discharged . Record review of a progress note dated [DATE], on Resident #1's electronic record stated the following:…

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, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of three (400 Hall Medication Cart) treatment carts reviewed for medication storage. The facility failed to ensure the 400 Hall Medication Cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings include: In an observation and interview on 09/26/23 at 7:48 AM, the 400 Hall Medication Cart was unlocked with the keys sitting on top of the cart. The medication cart was unattended and there were no staff in the immediate area. The medication cart was near the main entrance, so there were several staff and residents observed in close proximity to the medication cart. RN A entered the hallway from a resident's room across the hallway from where the medication cart stood. RN 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 coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for one (Resident #1) of one resident reviewed for PASRR services. The facility failed to submit Resident #1's PASRR Comprehensive Service Plan (PCSP) form in the LTC Online Portal for Resident #1 by the specific deadline. This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Review of Resident #1's face sheet, dated 09/01/23, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included dementia, moderate intellectual disabilities, and cognitive communication deficit. Review of Resident #1's care plan, undated, reflected she was PASRR…

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.