Kirkwood Manor

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 2 medication rooms (Medication room station-2 for 100 and 500 hall) reviewed for medication storage. The facility failed to ensure the narcotic box inside the refrigerator for medications in the medication room station-2 for 100 and 500 hall was permanently affixed to the refrigerator. This failure could place residents at risk of not having controlled medications as ordered due to diversion of medication. Findings included:Observation on 04/08/2026 at 2:02 p.m. revealed there was a refrigerator inside the medication room station-2 for 100 and 500 hall, and the refrigerator was for medications. Further observation revealed one narcotic box for controlled medications was inside the refrigerator, but the narcotic box was affixed to one of refrigerator shelves, and the shelf was not permanently affixed to the refrigerator, so anybody could remove freely the shelf that the narcotic box was affixed to. Inside the narcotic box, there was…

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

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 1 of 1 kitchen observed for plate preparation. The facility failed to ensure dietary staff properly air-dried insulated domes for tops of plates prior to meal service observed on 04/09/2026. These failures could place residents who received meals and/or snacks from the kitchen at risk of food born illness. The findings included: Observation on 04/09/2026 at 11:29 a.m. revealed Dietary Aide N placing plates on trays once they were prepared and covering them with insulated domes that had pooling water in them and as the Dietary Aide N would turn them over and place them on the plates of approximately 7 plates water would dribble across the plates. Dietary Aide N would then place the trays on the rack that were sent to 600 hall. Observation and interview on 04/09/2026 at 11:37 a.m. the Dietary Supervisor observed the insulated domes being placed on plates, that had not been dried properly 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 implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Residents #1) of 27 residents reviewed, in that: Resident #1's personal refrigerator located in her room contained a small plastic container and some food wrapped with kitchen aluminum foil with no date and no label on 04/07/2026. The failure could place the residents at risk for food borne illness. The findings included:Record review of Resident #1's face sheet, dated 04/10/2026, revealed the resident was a [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of pneumonia (infection that affects one or both lungs), dysphagia (difficulty swallowing), and muscle wasting and atrophy (decrease in muscle size and mass, which results in reduced muscle strength and function). Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records on each resident were complete, readily accessible, and contained the results of any preadmission screening and resident review evaluations and determinations conducted by the State for 2 of 5 residents (Resident #13, and #81), reviewed for Administration. 1. The facility failed to ensure Resident #13's PASARR level 1 screening, and PASARR level 2 evaluation were included in the resident's EHR. 2. The facility failed to ensure Resident #81's PASARR level 2 evaluation, and her specialized service plans were included in the resident's EHR. This failure could place residents at risk of a delay in or not receiving their needed care and specialized services, and decreased continuity of care.The findings were: 1. Record review of Resident #13's face sheet dated 4/8/26 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13's diagnoses included major depressive disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide 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 5 residents (Resident #1) reviewed for accurate administration of medications. The facility failed to ensure Resident #1's mediation order of cloNIDine HCI (a medication used to treat blood pressure and/or heart rate) was entered as prescribed by a physician. This failure could place residents at risk of not receiving their prescribed medications correctly and a decreased quality of life.The findings include: Record review of Resident #1's face sheet dated 3/30/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension (high blood pressure), heart failure, unspecified (heart is not pumping effectively), and unspecified atrial fibrillation (irregular heart rhythm). 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 3 residents (Resident #1) reviewed for pharmacy services. LVN A administered Resident #1's insulin from a flex pen (Aspart) for diabetes at lunchtime to Resident #1, when it was not labeled with the resident's name. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Record review of Resident #1's face sheet, dated 06/03/2025, revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: cerebral palsy (a group of neurological disorders that affect movement, balance and posture), type 2 diabetes mellitus (the most common form of diabetes characterized by 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 ensure all drugs and biologicals were labeled for 1 of 3 residents (Resident #1) reviewed for medication labeling. 2. An insulin flex pen (Aspart) for diabetes had no resident's name labeled and was found on the 400-hall medication cart on 06/03/2024 and assumed by LVN A to belong to Resident #1. This failure could place residents at risk of use of the medication for more than one resident which could result in contamination of a blood borne pathogen. The findings included: Record review of Resident #1's face sheet, dated 06/03/2025, revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: cerebral palsy (a group of neurological disorders that affect movement, balance and posture), type 2 diabetes mellitus (the most common form of diabetes characterized by the body's inability to properly use insulin, leading to high sugar levels), mild intellectual…

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 resident received care and services safely and the physical layout of the facility maximized resident independence and did not pose a safety risk; provided maintenance services necessary to maintain an orderly, and comfortable interior; provide adequate and comfortable lighting levels in all areas; for 2 of 2 shower rooms (600 hall shower on E and W side), maintained shower free of saftery hazards for 1 of 2 Showers (600 Hall Shower), and 1 of 1 Resident's room (Resident #68) reviewed for safety hazards. 1. The water temperature in the 600 E shower room reached 95.5 degrees and the water temperature in the W shower room reached 97.1 degrees. The safe water temperature range should be 100 to 110 degrees. 2. There was a long hole on a wall around an electrical outlet beside Resident #68's bed. 3. There was broken tiles in the 600 E shower room for at least a couple of months. These failures could place residents at risk 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 establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 residents (Residents #52, #109, and #27) of 29 residents and for 1 of 2 shower rooms (600 W hallway) reviewed for infection control practices. 1. LVN-C provided colostomy (opening for the colon through the belly) care for Resident #52 and failed to change her gloves without sanitizing or washing her hands. 2. LVN-A entered Resident #109's room, who was on EBP, on 02/19/2025 at 4:40 p.m. and failed to put on a gown when the LVN-A was administering medications to the resident via gastrostomy tube. 3. Medication Aide-I administered medications for high blood pressure to Resident #27, the Medication Aide-I used a blood pressure cuff of the monitor machine to take Resident #27's blood pressure without cleaning the cuff. 4. Nursing staff failed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure each PASRR Level 1 Screening done for each resident was correct for mental illness for 1 of 2 residents'(Resident #10) PASRRs reviewed, in that: Resident #10 had a PASRR Level 1 screening that did not indicate that she had a mental illness with a diagnosis of bipolar disorder and, the facility did not have Resident #10 screened again for possible services. This failure could cause the residents not to receive services needed to maintain the highest functional ability for their quality of life. The findings included: Record review of Resident # 10's face sheet dated 02/20/2025revealed an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included: CHF (congestive heart failure- a condition which the heart does not pump blood as well as it should), anxiety disorder, dementia, and bipolar disorder. Record review on of Resident # 10's Care Plan dated 11/06/2024 revealed Resident #10 was care planned for bipolar disorder…

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 comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 1 of 8 residents (Resident #110) reviewed for care plan revisions. 1. The facility failed to ensure Resident #110's care plan was revised to reflect order to release seatbelt and harness on wheelchair every 2 hours for 10 minutes. This deficient practice could place resident at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #110's face sheet, dated 02/19/2025, revealed the resident was a [AGE] year old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #110 had diagnostics of abnormal posture, unspecified intellectual disabilities, and cerebral palsy. Record review of Resident #110's MDS, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review revealed the facility failed to ensure the resident environment remained was free of accident hazards as is possible in residents received adequate supervision and assistance devices to prevent accidents for 1 of 6 Residents (Resident #187) observed for safety hazards. 1. Nursing staff failed to put down a floor mat used as a preventative device on the right side of Resident #187's bed. This deficient practices could affect any resident and could contribute to avoidable falls and accidents. The findings were: 1. Review of Resident #187's face sheet, dated 2/20/25, revealed she was admitted to the facility on [DATE] with diagnosis including unspecified Dementia. Review of Resident #187's Care Plan, dated 2/15/25, revealed she was a fall risk and some of the interventions included bed in lowest position and floor mats at bedside. Review of Resident #187's Fall Risk Evaluation, dated 2/15/25, revealed she was a high risk for falling related to disoriented x 2 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 observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bowel and bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #70) reviewed for incontinence care. When CNA-D was providing incontinent care to Resident #70 on 02/20/2025, CNA-D did not separate the resident's labia and did not clean the base of her labia. Then, CNA-D turned the resident to her left side and started cleaning the resident's bowel movement. However, the CNA-D did not clean Resident #70's bowel movement completely. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #70's face sheet, dated 02/18/2025, revealed a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 of 4 (Resident #70 and #52) reviewed for respiratory care. 1. Resident #70's physician order indicated Changing oxygen tubing and humidifier bottle every night shift every Wednesday, but the resident's oxygen tubing labeled 02/03/2025 was not changed every week per the physician's order. 2. Resident #52's oxygen nasal cannular and mask for Bi-pap were not covered in a plastic bag when they were not used. This failure could affect residents with oxygen therapy and could lead them to lack of care including possible infection by not following the physician orders. The findings included: 1. Record review of Resident #70's face sheet, dated 02/18/2025, revealed a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of coronary artery without angina…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #32) reviewed for pharmacy services. Resident #32's insulin flex pen (Lispro) for diabetes had an open date of 01/10/2025 found inside the 300-hall nursing cart on 02/19/2025. It should have been discarded 28 days after opening. The failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Record review of Resident #32's face sheet, dated 02/21/2025, revealed Resident #32 was a [AGE] year old female and admitted to the facility 04/11/2024 and re-admitted to the facility 12/26/2024 with diagnoses of anemia (the blood does not have enough healthy red blood cells and hemoglobin), chronic obstructive pulmonary disease (a group of lung…

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 all drugs and biologicals were stored in locked compartments for 1 of 3 medication carts (400-hall medication aide cart) and 1 of 4 residents (Resident #83) reviewed for storage. 1. The facility failed to ensure the 400-hall medication aide cart was locked when left unattended during passing medications. 2. Resident #83's insulin flex pen (NovoLog) for diabetes had no open date, found inside 200-hall nursing cart on 02/19/2025. Per facility policy the opened and undated insulin should have been discarded. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: 1. Observation on 02/19/2025 at 12:09 p.m. revealed the 400-hall medication aide cart was found unlocked and unattended on the 400 hallway when Medication Aide-H was passing medications on the 400-hall. This state surveyor was able to open all drawers revealing multiple…

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 enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #56) of 8 residents reviewed, in that: Resident #56's personal refrigerator located in her room was observed on 02/18/2025, and there was a small plastic cup inside the refrigerator, but no date and no label on the plastic cup. This deficient practice could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #56's face sheet, dated 02/21/2025, reflected the resident was [AGE] years old female and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: Parkinsonism (tremor, slowed movement, rigidity, and postural instability), urinary tract infection (bladder infection), hypertensive (high blood pressure), muscle wasting and atrophy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assured accurate administering of all drugs to meet the needs of residents for 1 of 8 residents (Resident #1) reviewed for pharmaceutical services, in that: The facility did not reorder Resident #1's Anastrozole for chemo treatment timely, resulting in Resident #1 missing 3 doses (06/21/24, 06/22/24, and 06/23/24) of Anastrozole. The noncompliance was identified as PNC. The PNC began on 06/24/2024 and ended on 06/25/2024. The facility had corrected the noncompliance before the survey began. These failures could place residents who receive medications administered by the facility at risk of not receiving the intended therapeutic benefit of their medication. The findings included: Record review of Resident #1's face sheet, dated 01/10/2025, revealed she was a [AGE] year-old female who originally admitted to the facility on [DATE], re-admitted to the facility on [DATE], and discharged on 06/24/2024…

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 interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #1), reviewed for medication errors. 1. The facility staff failed to hold Resident #1's digoxin (medication used to manage and treat heart failure and certain abnormal heart rhythms) per physician ordered parameters on 2/18/24 and 2/25/24. 2. The facility staff failed to administer Resident #1's midodrine (medication used to raise abnormally low blood pressure) as ordered to be given PRN every 8 hours for SBP<100 on 2/11/24, 2/18/24, 2/25/24, 3/3/24, and 3/13/24 (5 instances) when the resident's SBP was below 100. These failures could place residents at risk of a critically low pulse and blood pressures, inadequate blood flow, missed signs and symptoms of illness, hospitalization, and death. The findings were: Closed record review of Resident #1's face sheet, dated 3/24/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1…

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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for medical records. 1. The facility staff failed to document a blood pressure and a pulse prior to or after administration of Resident #1's digoxin (medication used to manage and treat heart failure and certain abnormal heart rhythms) that had ordered parameters to hold the medication if the blood pressure or pulse was outside of the parameters from 2/13/24 to 2/17/24, 2/19/24 to 2/24/24 and 2/26/24 to 3/13/24 (23 days). 2. The facility staff failed to document a blood pressure for Resident #1's midodrine (medication used to treat abnormally low blood pressure) every 8 hours as ordered to be given PRN every 8hours for low blood pressure from 2/1/24 to 2/29/24 (all of February), and 3/1/24 to 3/13/24 (13 days). These failures could place residents 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, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for kitchen sanitation during the initial tour. A. Food items were not clearly labeled to indicate safe preparation for or consumption by residents. B. Kitchen spatulas were not in good working condition and the rubber parts had tears. C. Food stored in the walk-in cooler were not completely covered. D. Kitchen Equipment was damaged and dirty. E. Areas of the kitchen floor appeared to be holding water and was dirty F. Kitchen equipment was stored on the floor. G. Nourishment rooms contained inoperable freezing units, contained expired food, and unlabeled food. These deficient practices could place residents at risk for cross-contamination and foodborne illness. Findings included: 1. The following items were viewed in the walk-in cooler: a. 6 large bags of a clear yellow substance had been removed from…

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

Based on interview and record review the facility failed to follow up on concerns discussed in resident's council meeting for 7 of 9 residents reviewed for resident council. The facility failed to show follow up on complaints and grievances made in resident council. This failure could place residents that participate in a resident council at risk of not having the right to their concerns and grievances followed through with. Finding included: Review of resident council minute meetings revealed complaints about food but no information regarding how the concerns and complaints were followed up on. In a group interview on 1/24/24 at 2:00 p.m. seven residents in a confidential resident group interview said they have made the same complaints about food over the last year. They stated they have continued to have the same issues with food being cold, not appetizing, not receiving follow up or follow through with the voiced concerns regarding food. The same example was given by multiple residents in the confidential group meeting of the meal prior to the day of the meeting that consisted of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident 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 three (Resident #23, # 74, and #164) of three residents reviewed for care plans in that: 1. The facility failed to ensure Resident #23's comprehensive care plan addressed the residents individual needs and indicated Resident #23 needed to stop smoking. 2. The Facility failed to ensure Resident #74's comprehensive care plan addressed Resident #74's fluid restriction due to kidney failure/dialysis. 3. The facility failed to ensure a comprehensive care plan for Resident #164 was completed since the resident's admission. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. The Findings included: 1. Review of…

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

Based on observation, interview and record review, the facility failed to provide pharmaceutical services. Including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications on 3 of 3 medication storage rooms reviewed for pharmacy services. The facility did not dispose of loose medications, expired syringes and expired odor eliminators bottles from the medication storage room. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: During an observation on 1/23/20204 at 11:24 a.m., of the medication room for 100 and 500 halls, there were 17 of 32 bottles of expired Assure C Odor Eliminator bottles. An expired 12 pack of beer. A loose white round pill was found in a cat food box under the sink. During an interview on 1/23/2024 at 11:24 a.m., RN A verified the expired odor eliminators, beer and loose pill. She stated that the medication aides or nurses should be reconciling the medication rooms. She stated that any loose medication 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 interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and what, if any, action has been taken to address them, for 3 of 7 residents (Residents #33, #65, and #12) whose records were reviewed for pharmacy services. The facility failed to ensure the physician provided a precise clinical rationale in response to the consulting pharmacist's recommended changes for medication regimen review. This failure could place residents at risk for significant health status declines. The findings included: Record review of Resident #33's face sheet dated, 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis including cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #33's quarterly MDS Assessment, dated 11/20/2023, reflected Resident #33 was taking antidepressant medication. 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.

Based on record review and interview, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 14 of the 15 staff members (the ADM, the DON, ADON, LVN H, RN C, LVN I, SW, AD, DM, DOR, CNA B, CNA A, CNA C, CNA D, CNA E) reviewed for mandatory training, in that: Fourteen staff members (the ADM, the DON, ADON, LVN H, RN C, LVN I, SW, AD, DM, DOR, CNA B, CNA A, CNA C, CNA D, CNA E) reviewed for mandatory training had not received training regarding the facility's QAA-QAPI program. This failure could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. The findings included: Record review of employee files reflected no documented evidence the following employees received training regarding the QAPI program: -ADM was hired on 11/01/2019 -DON hired on 12/15/2023 -ADON, hired on 06/07/2021 -LVN H, hired on 05/09/2022 -RN C, hired on 09/05/2023 -LVN I, hired on 07/01/2022 -SW, hired on 08/03/2021 -AD, hired 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.

Based on record review and interview, the facility failed to ensure all staff received training in compliance and ethics for 14 of the 15 staff members (the ADM, the DON, ADON, LVN H, RN C, LVN I, SW, AD, DM, DOR, CNA B, CNA A, CNA C, CNA D, CNA E) reviewed for mandatory training, in that: Fourteen staff members (the ADM, the DON, ADON, LVN H, RN C, LVN I, SW, AD, DM, DOR, CNA B, CNA A, CNA C, CNA D, CNA E) reviewed for mandatory training had not received training regarding compliance and ethics. This failure could place residents at risk of receiving inadequate care from staff who are uneducated on compliance and ethics. The findings included: Record review of employee files reflected no documented evidence the following employees received training regarding compliance and ethics: -ADM was hired on 11/01/2019 -DON hired on 12/15/2023 -ADON, hired on 06/07/2021 -LVN H, hired on 05/09/2022 -RN C, hired on 09/05/2023 -LVN I, hired on 07/01/2022 -SW, hired on 08/03/2021 -AD, hired on 08/02/2022 -DM, hired on 11/01/2019 -DOR, hired on 11/01/2019 -CNA B, hired on 07/25/2022 -CNA A, hired…

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 reasonable accommodation of resident needs for 1 of 4 (Resident #30) residents reviewed for call lights in that: The facility failed to ensure Resident #30's call light was within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed and risk of falling. The Findings Included: Record review of Resident #30's face sheet, dated 01/25/2024 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses which included traumatic brain injury (usually results from a violent blow or jolt to the head or body), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle wasting and atrophy of the left and right hand (Muscle wasting is a loss of muscle mass due to the muscles weakening and shrinking), non- traumatic intracerebral hemorrhage (blood vessel in the brain ruptures and causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents had the right to formulate an advanced directive for 2 of 2 residents (Resident #33, #92) reviewed for advance directives. Resident #33's OOH-DNR form was invalid because the attending physician's date signed was missing from the form. Resident #92's OOH-DNR form was invalid because the notary's date signed was missing from the form. This failure could result in resident DNR's not being properly executed. The findings included: Record review of Resident #33's face sheet dated, 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with a diagnosis of Cerebral Infarction (the pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #33's comprehensive person-centered care plan, dated 09/27/2023 reflected [Resident #33] and family have elected DNR status with an initiated date of 09/22/2022. Record review of Resident #33's clinical records reflected an OOH-DNR, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 5 (Resident #87) resident room bathrooms. The bathroom sink faucet sprayed out water onto the floor when turned on. This failure could place residents at risk for an unsafe and unsanitary environment. The Findings included: Interview and observation with Resident #87 of room [ROOM NUMBER] in the resident's bathroom on 1/23/2024 at 11:17 a.m., revealed the resident showed the State Surveyor while in the bathroom and stated you have to turn on the faucet like this and low because if you don't it spray you and it gets all on the floor, sometimes I forget and it all gets wet, It just makes a mess. Interview and observation on 01/24/2024 at approximately 6:30 p.m. with the MS, the MS said the faucet should not be like that. I have not seen that was reported but these things do happen. The MS stated, the town water supply causes a lot of build up in…

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

Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 calendar days of admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition for 2 of 8 residents (Resident #164 and # 108) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #164 was completed within 14 days after admission. The facility failed to code the MDS Assessment for Resident #108 correctly after discharge from the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of resident #164's face sheet dated 01/24/2024, revealed an admission date of 01/11/2024, Record review of resident #164's medical record revealed that as of 01/25/2024, the MDS assessments showed as due or overdue. Interview with MDS Coordinator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately assess and reflect the resident's status for 1 of 26 residents (Resident #96) reviewed for accuracy of assessments in that: Resident #96's diagnosis for hypertension (high blood pressure) was not reflected on the comprehensive assessment dated [DATE]. This failure could place other residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Review of Resident #96's electronic face sheet dated 01/26/2024 revealed Resident #96 was [AGE] years old and was admitted on [DATE] with diagnoses which included congestive heart failure, CVA (stroke), peripheral vascular disease (a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), diabetes, anxiety, depression, hypertension (high blood pressure), paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in…

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 ensure the resident environment remains as free of accident hazards as was possible for 1 of 4 (Resident #44) residents reviewed for accident hazards in that: Resident #44's bed was left in a high position after receiving incontinent care from CNA B. This deficient practice could affect residents emotionally and could result in injury. The findings included: Record review of Resident #44's face sheet dated 01/25/2024 revealed an [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Diabetes a chronic (long-lasting) health condition that affects how your body turns food into energy, chronic obstructive pulmonary disease (COPD)(diseases that cause airflow blockage and breathing-related problems), muscle wasting and atrophy of right and left shoulder and right and left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were provided the fluids to maintain proper hydration for 1 of 1 (Resident #74) resident reviewed for fluid restriction in that: Resident #74's fluid restriction was not maintained as ordered, broken down as to how much nursing and dietary was to serve for meals, and nursing to use for medications being given. This failure could place residents at risk of not receiving proper hydration and could result in the residents being dehydrated. The findings included: Review of Resident #74's face sheet revealed the resident was admitted on [DATE] with diagnoses which included end stage renal disease, cerebral palsy, anemia, diabetes with diabetic neuropathy, hypertension, anxiety, depression, peripheral vascular disease and chronic obstructive pulmonary disease, Review of Resident #74's care plan dated 11/20/2023 revealed a care plan that addresses hemo-dialysis related to renal failure with an intervention for Fluid Restriction:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 8 (Resident #72) reviewed for respiratory care. Resident #72's oxygen was set at 2 liters rather than the physician's order for 4 lpm and there was no humidifier bottle. This failure could affect residents administered oxygen and could lead to residents not receiving the therapeutic effects of oxygen; and could lead to a diminished quality of life. The findings were: Record review of Resident#72's face sheet, dated 1/24/2024,revealed the resident was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (disease that cause airflow blockage and breathing-related problems) and chronic respiratory failure with hypoxia (not enough oxygen in your blood). Record review of Resident#72's MDS assessment (minimum data set), 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 record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 2 (Resident #12 & #99) of 7 Residents, reviewed for unnecessary psychotropic medications. The facility failed to 1. Ensure the medication (Ativan) was administered to treat a specific, clinically diagnosed illness for Resident #12. 2. Ensure a PRN psychotropic medication order was limited to fourteen days for Resident #12. 3. Ensure the medication Sertraline was administered to treat a specific, clinically diagnosed illness for Resident #99. This failure could affect residents who received psychotropics in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings included: Record review of Resident #12's face sheet, dated 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] diagnoses including dementia (a group of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to arrange an appointment with an outside resource for 1 of 3 residents (Resident #94) reviewed for the use of outside resources, in that: The facility did not have an order in Resident #94's electronic medical record for follow up care with the neurologist, nor follow up appointment. This failure could place residents at risk of not receiving needed medical care. Findings included: Resident #94's face sheet, dated 01/26/2024, revealed Resident #94 was admitted on [DATE] and had diagnoses that included: intellectual disability, unspecified, epilepsy, deaf nonspeaking, cerebral palsy, muscle wasting and muscle atrophy. Review of Resident #94's electronic medical record revealed a progress note from a community neurologist stating Resident #94 was seen on 10/23/2023 by the neurologist and had been referred by MD Z . Review of Resident #94's electronic medical record and order summary page dated did not reveal an order for continued neurological services, nor…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 1 residents (Resident #94), The facility failed to document the clinicial rationale or complete medication regimen for Resident #94. This failure could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. The findings included: Review of Resident #94's face sheet, dated 01/26/2024 revealed, Resident #94 was admitted on [DATE] and had diagnoses that included: intellectual disability, unspecified, epilepsy, deaf nonspeaking, cerebral palsy, muscle wasting and muscle atrophy. Review of Resident's most recent medical provider progress note with a service date of January 5, 2024 written by NP X and signed on 01/13/2024 at 6:25 p.m. did not document the resident's complete medication regimen nor provide clinical rationale. Interview…

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/resident representatives were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 of 2 Residents (Resident #1) reviewed for resident rights in that: The facility failed to notify Resident #1's Medical Power of Attorney or emergency contact after a behavioral incident when the resident did not have the cognitive ability to make informed medical decision before before receiving psychiatric services. This failure could place residents and their resident representatives at risk for not being informed about care and treatments that may affect the resident's well-being. The findings included: Review of a resident's face sheet dated 11/30/2023 indicated Resident #1 was an 82 - year- old initially admitted on [DATE] with diagnoses that included but 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 record review, the facility failed to report the results of all investigations to the State Survey agency within 5 working day of the incident for 1 of 3 residents (Resident #1) reviewed for abuse and neglect. The facility did not provide the state agency with a provider investigation within 5 working days. This failure could place residents at risk of injury, abuse and neglect. Findings included: A face sheet dated 11/30/2023 indicated Resident #1 was an [AGE] year old initially admitted on [DATE] with diagnoses that included but not limited to the following: myopathy (disease that affects the muscled that control voluntary movement in the body), Cerebral infarction (stroke due to disrupted blood flow in the brain), and diabetes (disease that results in too much sugar in the blood). An MDS dated [DATE] revealed Resident #1 had a BIMS of 2 indicating severe cognitive impairment. An incident report dated 08/31/2023 at 1:02 pm revealed an unidentified resident was sitting at their usual dining table, when…

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.