Broadmoor Medical Lodge

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of four direct care staff (RN C) reviewed for other environmental conditions. The facility failed to ensure that RN C did not leave a container of germicidal wipes on top of the nurse's cart unattended on 03/04/2026. This failure could result in having an environment that was not safe for the residents, staff, and public. Findings included: During an observation on 03/04/2026 at 11:41 AM revealed a container of germicidal wipes (substance that destroys germs and microorganisms) was on top of an unattended cart parked in the hallway. It was observed that several residents were passing by the hallway. During an observation on 03/04/2026 at 11:45 AM revealed RN C went inside a resident's room to administer medications. He closed the door while administering medications. He left his cart outside the resident's room with the container of germicidal wipes still on top of his cart. The container of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 3 of 15 residents (Residents #3, #4 and #5) reviewed for nutrition. 1. The facility did not ensure Resident #3 was given double protein portion as ordered by the physician. 2. The facility did not ensure Resident #4 was given ice cream and a shake as ordered by the physician. 3. The facility did not ensure Resident #5 was given a shake as ordered by the physician. These failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.Findings Included: 1. Record review of Resident #3's face sheet, dated 11/19/25, reflected Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included hemiplegia (paralysis that effects on side of the body) affecting left non dominant side. Record review of the nutrition/dietary note dated 04/08/25 reflected the dietician recommended…

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 incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 2 residents (Resident #2) reviewed for PASARR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.Findings included:Record review of Resident #2's face sheet, dated 11/19/25, reflected Resident #2 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included major depressive disorder and anxiety. Record review of Resident 2's significant change in status, dated 04/07/25, reflected Resident #2 rarely/never made herself understood and rarely/never understood others. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives through effective communication for 1 of 2 residents (Resident #1) reviewed for hospice services. The facility failed to communicate with hospice on 08/13/25 when Resident #1 fell, and on 10/17/25 when Resident #1 received bruises. This deficient practice 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. The findings included: 1. Record review of Resident #1's face sheet, dated 11/21/25, indicated he was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and stroke. Record review of Resident 1's significant change in status, MDS assessment, dated 08/20/25, indicated Resident #1 was sometimes understood and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 4 of 4 resident reviewed for pharmacy services. (Resident's #5, #11, #49, and #50) The facility failed to ensure Resident #11's ordered alprazolam (antianxiety) medication was available for administration on 11/26/2024, 11/27/2024, 11/28/2024, and 11/29/2024, which resulted in 11 missed doses of her antianxiety medication. The facility failed to ensure Resident #50's ordered Letrozole (hormone treatment for breast cancer) medication was available for administration 12/03/2024. The facility failed to ensure Resident #49's tramadol (scheduled ll pain medication) was accurately reconciled on 12/03/2024. The facility failed to ensure Resident #5 was not administered Hydrocodone 10/325 milligrams out of the ordered administration times on 12/04/2024. These…

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 assessments accurately reflected the resident status for 1 of 18 residents (Resident # 14) reviewed for MDS assessment accuracy. The facility failed to code Resident #14's hospice accurately. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #14's face sheet, dated 12/04/24 indicated Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(forgetfulness), seizures, anxiety (uneasiness or fear), and high blood pressure. Record review of Resident #14's physician orders dated 07/27/24 indicated an order for {name} hospice. Record review of Resident #14's quarterly MDS assessment, dated 11/08/24, indicated Resident #14 was not on hospice service. Record review of Resident #14's care plan dated 10/29/24 indicated Resident #14 had a terminal prognosis and was on hospice service.…

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 review and revise the person-centered care plan to reflect the current condition for 1 of 3 (Resident #49) residents reviewed for care plan revisions. The facility failed to revise Resident #49's care plan to remove her wound care when she no longer had a wound. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: Record review of Resident #49's face sheet dated 12/04/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), Multiple Sclerosis (a chronic disease that damages the central nervous system), depression(a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily) and high blood pressure. Record review of Resident #49's quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 1 of 18 Residents (Resident #37) reviewed for accidents and hazards. The facility failed to ensure Resident #37 had on her wander guard bracelet on 12/2/24 and 12/3/24. This failure could place residents at risk of elopement, injury, or harm. Findings included: 1.Record review of Resident #37's face sheet, dated 12/04/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory), Schizophrenia (a chronic mental disorder that affects a person's ability to think, perceive reality, and interact with others), and depression (sadness). Record review of Resident #37's quarterly MDS assessment, dated 11/21/24, indicated Resident #37 understood and was understood by others. Resident #37's BIMS score was a 10 indicating her cognition was moderately impaired. The MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #25) reviewed for (DRR) Drug Regimen Review. The facility failed to implement the pharmacy recommendations for Resident #25's medications that contained acetaminophen. This failure could place residents at risk for adverse side effects and not receiving medications at the most effective dosage. The findings included: Record review of the order summary report, dated 12/04/2024, reflected Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (age-related degenerative brain condition, meaning it causes parts of your brain to deteriorate) and chronic pain. Record review of the quarterly MDS assessment, dated 11/21/2024, reflected Resident #25 had no speech and was rarely/never understood by others. The MDS reflected Resident #25 was rarely/never able to understand others. The MDS reflected…

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 store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 medication carts (Hall 300 nurse medication cart and 300 hall medication cart) of 6 medication carts reviewed for medication storage. The facility failed to ensure MA B secured a controlled narcotic medication when he left a Tramadol inside a medication cup sitting on the 300-hall medication cart when he walked to the nurse's station. The facility failed to ensure RN F secured the 300-hall nurse cart when she entered the room, standing behind the privacy curtain to obtain a blood pressure, then again when she went behind the privacy curtain to obtain the over-the-bed table to prepare the supplies, then lastly when she closed the door and stepped behind the privacy curtain to administer the gastrostomy tube medications. Theseis failures could place residents at risk of ingesting medications not prescribed, and access to sharps (needles and lancets).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 3 residents (Resident #49) reviewed for therapeutic diets. The facility did not ensure Resident #49 was given her ice cream as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of Resident #49's face sheet dated 12/04/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), Multiple Sclerosis (a chronic disease that damages the central nervous system), depression(a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily) and high blood pressure. Record review of Resident #49's quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 resident reviewed (Resident #34) for special eating equipment and assistance when consuming meals. The facility failed to provide Resident #34's physician ordered plate guard. Thisese failures could place residents at risk for harm by weight loss, diminished independence, and self-esteem. Findings included: Record review of a face sheet dated 12/04/2024 indicated Resident #34 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of dementia (memory loss), stroke, hemiplegia (paralysis or weakness of one side) and a contracture (shortening or hardening of muscle or tendon leading to rigidity) of the left hand. Record review of a Quarterly MDS dated [DATE] indicated Resident #34 was understood and understood…

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

Based on observation, interview, and record review, the facility failed to ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving. The facility did not ensure hair restraints were worn appropriately by the Dietary Manager. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 12/02/24 at 11:10 a.m., revealed the Dietary Manager came into the kitchen and did not apply his hair or beard restraint. The Dietary Manager was in the freezer and storage area without his hair and beard restraint on. The Dietary manager's facial and beard hair was approximately 1/4 to 1/2 inch long. During an interview on 12/02/24 at 11:49 a.m., the Dietary Manager said he had ran to the store and heard that the state was in the facility and he was trying to get back and see what he needed to do. The Dietary Manager said he went into the freezer and the storage room without his hair or beard restraint on. He said he knew it was important to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 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 2 of 18 residents (Resident #14, and Resident #129) reviewed for hospice services. The facility failed to maintain Resident #14's, and Resident #129's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. 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. The findings included: 1.Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 2 of 18 residents (Resident #45, and Resident #49) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse performed hand hygiene while performing wound care for Resident #45 who had wounds, on 12/03/24. 2. The facility failed to ensure CNA S changed gloves or performed hand hygiene while providing incontinent care for Resident #49 who was incontinent, on 12/03/24. These failures could place residents, and staff at risk of the spread of infections. Findings included: 1.Record review of Resident #45's face sheet, dated 12/05/24 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included pressure wounds (areas of damaged skin 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.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment allowing the resident to use his or her personal belongings to the extent possible for 1 of 1 shower reviewed for resident rights. The facility failed to ensure the shower did not have trash on the floor on 5/24/24. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life. Findings included: During an observation on 5/24/24 at 9:11 a.m. the facility's central shower had a disposable razor that was on the floor next to the wall and trash in the floor of the shower room. During an observation on 5/24/24 at 10:16 a.m. the central shower room had a disposable razor that was on the floor next to the wall and trash on the floor of the shower room. During an observation on 5/24/24 at 1:00 p.m. the central shower had a disposable razor, used gloves, trash, and popcorn on the floor. During an interview on 6/11/24 at 10:30 a.m., CNA A said the CNAs were responsible for cleaning trash and razors off…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 6 residents (Resident #1 and Resident #2) reviewed for baseline care plans. The facility failed to ensure Resident #1 and Resident #2 had baseline care plans completed within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services. Findings included: 1. Record review of the face sheet dated 2/28/24 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including anxiety, diabetes, hypotension (decreased blood pressure, chronic kidney disease, lack of coordination, shortness of breath. Record review of the MDS dated [DATE] indicated Resident #1 admitted to the facility on [DATE]. The MDS indicated Resident #1 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 in the facility's only kitchen reviewed for food safety. 1.The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to ensure the ice machine vent was free from greasy residue buildup with dust. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the emergency water supply was monitored and changed out as needed 5. The facility failed to ensure handwashing sink #1 was free from debris in the sink. 6. The facility failed to ensure food items stored in the walk-in refrigerator and dry storage room were not left open to air or secured close. 7. The facility failed to ensure hazardous tools were not left out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, 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 3 out of 4 residents reviewed. (Resident #133, Resident # 57, and Resident #33) The facility failed to develop person centered care plans for antibiotic use, medical management of seizure disorder, anxiety, depression and fall prevention for Resident #133. The facility failed to develop interventions/tasks within the person-centered care plans for hypothyroid disease, depression, malnutrition, and shortness of breath. They also failed to develop care plans for medical management of insomnia and allergy to penicillin for Resident # 57. The facility failed to develop person centered care plans for medical management of depression, insomnia, NPO…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 (Hall 300) of 8 halls and 1(Nurses Station #1) of 2 nurses stations and one resident (#29) of 8 residents and one (confidential meeting) reviewed for Environment. The facility failed to repair or replace the flooring and carpet areas around the 300 hall and nurses' station #1, which was reported to the Maintenance Director months ago by staff and documented in the maintenance logbook. These failures placed residents at risk of being potentially at risk of tripping and falling which could cause injury, pain, and distress, resulting in a decrease in their quality of life and psycho-social well-being. Findings included: Record review of Resident #29's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted on [DATE] and as of this assessment her BIMS score was 09 (moderate cognitive impairment), supervision with setup help for locomotion…

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 the facility must develop and implement a baseline care plan for 2 of 4 residents reviewed for baseline care plans. (Resident #43 and Resident #33) The facility failed to develop person baseline care plans within 48 hours of admission for Resident #43 and Resident #33. Findings included: 1.Record review of Resident #33's Quarterly MDS dated [DATE] revealed he was an [AGE] year-old male admitted on [DATE]. He had a diagnosis of coronary artery disease, hypertension (high blood pressure), pneumonia, MDRO (multidrug resistant organism), urinary tract infection, and generalized muscle weakness. He had a BIMS of 6 (severe cognitive impairment). He required the use of a wheelchair, extensive assistance, and oxygen therapy. Record review of Resident # 33's clinical assessments log (where baseline care plans can be found) dated from 09/27/23 to 10/12/23 revealed there was no baseline care plans completed. 2.Record review of Resident #43's Quarterly 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, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and received adequate supervision for 3 residents (#8, #36 and #37) of 10 residents reviewed for supervision. The facility failed to have adequate staff supervision in the 300 hall Tea/Bistro room and main dining room, to ensure the pureed and mechanically soft diet residents were not at risk of getting or receiving solid foods from the snack stands. This failure could potentially place residents at risk of eating food not doctor ordered and unsafe for them to eat and drink, which could cause them to choke or aspirate, resulting in a decreased quality of life and psycho-social well-being. Findings included: Resident #8's Quarterly MDS assessment dated [DATE] revealed an [AGE] year old female who admitted on [DATE] her BIMS Score was 03 (severely impaired cognition), extensive one person assistance for eating and upper extremity impairment on one side, used…

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.