Ridgecrest Healthcare And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 28 residents (Residents #5 and Resident #112) reviewed for care plans. 1. The facility failed to ensure Resident #5's care plan included her fall on 07/19/25 and the use of the non-strip strips and cervical collar (a collar used around the neck to support the neck and spinal cord after an injury) that should always remain in place. 2.The facility failed to update Resident #112's care plans for nectar thick liquids on 06/27/25. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.1.Record review of Resident #5’s face sheet dated 07/31/25 indicated she was a [AGE] year-old female who re-admitted to the facility…

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 receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 28 residents (Resident #110) reviewed for ADLs. The facility failed to provide Resident #10's showers as scheduled for the month of July 2025. These failures could place residents at risk of not receiving needed services and care, decreased self-esteem, and a decreased quality of life. Findings included: Record review of Resident #110's face sheet dated 07/31/2025 indicated he was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), atrial fibrillation (irregular, often rapid heart rate), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). 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 interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #123) The facility failed to begin neurological checks when Resident #123 had an unwitnessed fall on 07/30/25 at 3:10 PM. These failures could place residents at risk of a delay in treatments for the resident's conditions.Findings included: Record review of Resident #123's face sheet dated 7/31/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which results in too much sugar in the blood stream), high blood pressure, cerebrovascular disease(group of conditions that impact the brain's blood flow), normal pressure hydrocephalus (where excessive spinal fluid builds up in the ventricles), and history of falling. Record review of Resident #123's admission MDS dated [DATE] indicated she could understand others 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 the resident environment remains as free of accident hazards as is possible for 1 of 3 residents (Residents #11) reviewed for accident hazards. The facility failed to ensure Resident #11 did not smoke a cigarette in the facility on 12/08/2024 and 07/11/2025. The facility failed to ensure Resident #11 was provided supervision while smoking on 07/29/2025. These failures could place residents at risk of accidents, injuries, or burns. Findings included: Record review of Resident #11's face sheet dated 07/31/2025 indicated he was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), schizoaffective disorder bipolar type (mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression,…

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 needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 5 residents reviewed for respiratory care. (Resident #42) The facility failed to administer Resident #42's oxygen as ordered on 07/28/25, 7/29/25, and 7/30/25. This failure could place residents who receive respiratory care at risk for developing respiratory complications.Findings included: Record review of Resident #42's face sheet dated 07/31/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung condition caused by damage to the airways that limit airflow), lung cancer, and acute respiratory failure (lung condition when the lungs cannot exchange oxygen and carbon dioxide properly). Record review of Resident #42's admission MDS assessment dated [DATE], indicated she was sometimes understood and sometimes…

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 drug regimen was free from unnecessary drugs for 1 of 5 residents reviewed for medications. (Resident #123) The facility failed to ensure Resident #123 had a diagnosis or adequate indication for quetiapine (Seroquel) (An antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). The facility failed to ensure the proper consent form 3713 was completed prior to administering the medication quetiapine (Seroquel). This failure could place residents who received antipsychotic medications at risk of receiving unnecessary medication. Record review of Resident #123's face sheet dated 7/31/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which results in too much sugar in the blood stream), high blood pressure, cerebrovascular disease, normal pressure hydrocephalus, and history of falling. The face sheet did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 6 residents (Resident #60) and 1 of 3 medication carts (300-Hall nurse medication cart) reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #60's medication labels for her amlodipine, carbidopa-levodopa, clopidogrel, and hydralazine matched her physician order. 2. The facility failed to ensure LVN D secured the 300-Hall nurse medication cart when it was not in use and unattended on 07/29/2025. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. Record review of Resident #60's face sheet dated 07/31/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included essential (primary) hypertension (high blood…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #7) reviewed for hospice services. The facility failed to maintain Resident #7's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, and physician recertification. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included:Record review of Resident #7's face sheet, dated 07/31/25, indicated he was an [AGE] year-old male,…

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 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 6 residents (Resident #22 and Resident #53) and 2 of 2 staff (Treatment Nurse and Laundry Supervisor) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse changed her gloves when she removed Resident #22's dirty dressing on 07/29/25. 2. The facility failed to ensure the Treatment Nurse used proper PPE when providing wound care for Resident #53 on 07/30/25. 3. The facility failed to ensure the Laundry Supervisor was aware of Resident #53 being under contact isolation. These failures could place residents and staff at risk for cross-contamination and the spread of infection.Findings included: 1. Record review of Resident #22’s face sheet dated 07/31/25, indicated an [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 observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 21 residents (Resident #1 and Resident #2) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E wore PPE while providing catheter care on Resident #2 on 03/26/25. 2. The facility failed to ensure LVN A wore the proper PPE (gown and gloves), changed her gloves, and performed hand hygiene while performing wound care on Resident #1 on 03/25/25. These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. Findings Include: 1.Record review of a face sheet dated 03/26/25, indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of chronic kidney disease (your…

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 implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 10 residents (Resident #1) reviewed for developing and implementing abuse policies. The facility failed to follow its policy to report to the Texas Health and Human Services Commission (HHSC) when Resident #1 alleged that LVN B did not do her treatment on 03/21/25 and she felt neglected. The facility staff did not report to the state agency that Resident #1 felt neglected by her missed wound treatment on 03/21/25. This failure could place residents at risk of neglect, abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 03/27/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included arthritis (conditions that cause joint pain, swelling, and stiffness), diabetes(is a chronic condition that happens when you have persistently high…

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 receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 (Resident #1) residents reviewed for quality of care. The facility failed to ensure that LVN B did Resident #1's left axilla wound treatment as ordered on 03/21/25. This failure could result in residents with wounds not having their treatments performed as ordered, wounds becoming infected, and decreased wound healing. Findings Included: Record review of Resident #1's face sheet, dated 03/27/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included arthritis (conditions that cause joint pain, swelling, and stiffness), diabetes(is a chronic condition that happens when you have persistently high blood sugar levels), anxiety(characterized by excessive and persistent worry, fear, and nervousness) and dementia(diseases that affect memory, thinking,…

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, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury for 1 of 3 (Resident #1) residents reviewed for abuse and neglect. The facility staff did not report to the state agency Resident #1's bruising to left brow, temple, and behind right knee on 9/22/24. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure),…

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 practice and the comprehensive person-centered care plan for 1 of 2 (Resident #1) residents reviewed for quality of care. The facility failed to ensure Resident #1's right heel arterial wound treatment orders were updated in the electronic medical records. This failure could result in residents with wounds of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings Included: Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure), traumatic brain injury (a brain injury caused by an outside force, usually a violent blow to the head), dementia, and heart failure (a chronic condition in which the heart does not pump blood as good as it should).…

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 necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 3 (Resident #1) residents reviewed for pressure injuries. The facility failed to ensure Resident #1's pressure wounds to her sacrum (a triangular bone at the base of the spine) and left calf were treated as ordered by the Wound Care Physician. These failures could place residents at risk for worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure), traumatic brain injury (a brain injury caused by an outside force, usually a violent blow to the head), dementia, and heart failure (a 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 observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 1 of 4 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1 had orders for oxygen therapy. This failure could place residents at risk of not receiving a therapeutic level of oxygen therapy . Findings include: Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure), traumatic brain injury (a brain injury caused by an outside force, usually a violent blow to the head), dementia, COPD and heart failure (a chronic condition in which the heart does not pump blood as good as it should). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 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 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 1 of 3 staff (Treatment Nurse), and 2 of 2 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while performing wound care on Resident #1 and Resident #2 These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. Record review of the face sheet dated 10/3/24 indcated Resident #2 was an [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including diabetes, muscle weakness, lack of coordinations, and chronic kidney disease. Record review of the MDS dated [DATE] indicated 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.

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. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to ensure the ice machine, located in the facility's kitchen, was cleaned. The facility failed to ensure the tea dispenser was covered after being used. The facility failed to ensure kitchen equipment (food storage bins) were cleaned and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 06/13/24 from 09:05 AM to 09:21 AM in the facility's only kitchen reflected: Observation of the ice machine, in the facility kitchen revealed the ice scoop was stored…

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 areas in the facility for 6 (Resident #7, #26, #40, #76, #86, and#150) of 20 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #7's, #26's, #40's, #76's, #86's, and#150's rooms were cleaned and sanitized . This deficient practice could place residents at risk of living in an unclean and unsanitary environment. Findings included: Record review of Resident #76's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Chronic Obstructive Pulmonary Disease (constricted airway) and Respiratory Failure. Record review of Resident #76's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 14 (cognitively intact). 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, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Residents #26, #76 and #112) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #26's, #76's and #112's breathing masks were stored in a sanitary manner when they were not being used by the residents. The facility failed to ensure that Resident #76's CPAP mask properly fit the resident and ensured the resident's CPAP machine operated properly. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #76 Record review of Resident #76's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Chronic Obstructive Pulmonary Disease…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #11) of 1 resident reviewed for Care Plans. The facility failed to ensure Resident #11 was care planned for Dialysis. This failure could place the resident at risk of needs not being met. Findings included: Record review of Resident #11's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Renal (Kidney) failure and treatment for Dialysis. Record review of Resident #11's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 (cognitively intact ). The assessment also indicated the resident had an active diagnosis for Renal Failure 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.