Memorial Medical Nursing And Rehabilitation

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 safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to store clean cups properly to allow for air-drying. 2. The facility failed to store a mop and a broom in a sanitary manner in the utility closet. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 06/08/2025 at 11:52 AM in the dish room revealed there was one tray of 19 plastic mugs stored face-down on a wet tray. There were also two trays of ceramic mugs, each with approximately ten mugs, stored face down on a wet tray. There were no air-drying nets separating the plastic or ceramic mugs from the trays. During an interview on 06/08/2025 at 11:54 AM, the DM stated the trays were missing air-drying nets separating the bowls and cups from the trays. She had several such nets that were in use on other trays 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, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Resident #10 and 71) reviewed for infection control, in that: 1. While providing colostomy care for Resident #10, LVN C did not change his gloves or sanitize his hands after touching the privacy curtain and before starting the care. 2. a. While providing wound care for Resident #71, LVN A did not change her gloves or sanitize her hands after touching the privacy curtain and before starting the care. 2.b. While providing incontinent care for Resident #71, CNA D did not change his gloves or sanitize his hands during care. These deficient practices could place residents at-risk for infection due to improper care practices. These findings included: 1. Record review of Resident #10's face sheet, dated 06/10/2025, revealed an admission date of 05/28/2020, and a readmission date 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, record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #71) reviewed for privacy, in that: LVN A did not close Resident #71's privacy curtain while providing wound care on 06/10/2025. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #71's face sheet, dated 06/10/2025, revealed an admission date of 03/19/2024 and, a readmission date of 10/08/2024, with diagnoses which included: Chronic kidney disease (gradual loss of kidney function), Aphasia (result of a Stroke or Brain injury, and affects a person's ability to communicate), Type 2 diabetes mellitus (high level of sugar in the blood), Hemiplegia (Paralysis of one side of the body), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure) and, Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure).…

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 assessment accurately reflected the resident's status for 1 of 20 residents (Resident #75) whose assessments were reviewed. The facility failed to indicate Resident #75's current tobacco use on his significant change MDS dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #75's face sheet dated 06/08/2025 revealed the resident was admitted to the facility 02/10/2024 and readmitted on [DATE] with diagnoses that included: Hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side of the body following a stroke), chronic heart failure, schizoaffective disorder bipolar type (a mental health condition involving psychotic symptoms like hallucinations and delusions alongside mood episodes of mania and sometimes depression), and acute respiratory failure with hypoxia (a critical condition where the lungs cannot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder for level II resident review upon a significant change in status assessment for 1 (Resident #75) of 20 residents reviewed for resident assessments. The facility failed to refer Resident #75 for a level II resident review following a new diagnosis of schizoaffective disorder-bipolar type, added on 12/17/2024. This failure could place residents at risk of not having their mental health needs met by the facility and could place all residents at risk of harm by mentally unstable residents. Findings included: Record review of Resident #75's face sheet dated 06/08/2025 revealed the resident was admitted to the facility 02/10/2024 and readmitted on [DATE] with diagnoses that included: Hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side of the body following a stroke), chronic heart failure, schizoaffective disorder bipolar type (a mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents (Resident #11) reviewed for care plans. The facility failed to revise Resident #11's comprehensive care plan to reflect the resident's refusal to have her weight taken. This deficient practice could cause confusion for staff members responsible for providing direct care for residents and result in staff not respecting residents' wishes regarding care. The findings were: 1. Record review of Resident #11's face sheet dated 06/09/2025 revealed the resident was an [AGE] year old female with diagnoses that included: cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), cerebral palsy (a group of neurological disorders that affect movement, posture, and muscle coordination), schizophrenia (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who needed tracheostomy care were provided such care, consistent with professional standards of practice, for 1 of 1 residents (Resident #76) reviewed for tracheostomy care. The facility failed to provide tracheal care and suctioning according to professional standards for Resident #76. These deficient practices could result in the resident's not receiving the care and services ordered by the physician and a decline in health status and respiratory infection. Findings included: Record review of Resident #76's face sheet, dated 06/10/2025, revealed an admission date of 07/25/2024 with diagnoses that included: Anoxic brain damage (damage caused to the brain due to a lack of oxygen), Contractures (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), Aphasia (result of a Stroke or Brain injury that affects a person's ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure that nurses were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 6 residents (Resident #76 ) by 1 of 3 nurses (RN B) reviewed for competent staff, in that: The facility failed to provide tracheal care and suctioning according to professional standards for Resident #76. The failure could place residents at risk for not receiving nursing services by adequately trained and licenses nurses and could result in a decline in health and infection. The findings included: Record review of Resident #76's face sheet, dated 06/10/2025, revealed an admission date of 07/25/2024 with diagnoses that included: Anoxic brain damage (damage caused to the brain due to a lack of oxygen), Contractures (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), Aphasia (result of a Stroke or Brain injury that…

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 of 1 residents (Resident #5) reviewed, in that: The facility failed to ensure food items stored in Resident #5's personal refrigerator was labeled and dated. 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 #5's face sheet, dated 06/09/2025, reflected the resident was an [AGE] year old female and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: Schizoaffective Disorder a chronic mental illness that combines symptoms of both schizophrenia and a mood disorder, such as depression or mania), Muscle Weakness (loss of muscle tissue and strength), Dementia (group of symptoms that affect memory, thinking, 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, record review, and interview the facility failed to have an ongoing and effective pest control program for 1 of 4 halls (West hall) reviewed for pest control. The facility did not have an effective pest control program to eradicate the gnats in the facility. The facility failure placed residents at risk for infections and diminished quality of life. Findings included: Observation on 06/10/25 at 10:30 a.m. revealed while observing transfer care provided for Resident # 64 by CNA F, this surveyor observed 11-12 small flying black insects that looked like gnats on one of the side table in the room During an interview with CNA F on 06/10/2025 at 10:32 a.m., CNA F stated the flying black insect were present in the room and she added it happened often. She stated they reported to housekeeping every time they noted a problem with insects. During an interview on 06/10/2025 at 10:40 a.m., the DON stated the insects were present and alive in Resident #64's room. He added it was one of the thing they were working on and they were going to change the pest control company…

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 drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2's medication reconciliation log for the Schedule II medication (substances with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) Hydromorphone accurately reflected the number of doses administered. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain, and a decreased quality of life. The findings included: Record review of the facility provider investigation report written by the facility administrator dated 3/19/25, documented there were incomplete signatures on a residents narcotic log. The report further documented while RN D was counting narcotics with RN E a medication Hydromorphone 1 mg/ml, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain resident medical records that were complete and accurately documented for 1 of 2 residents (Resident #1) reviewed for clinical records. Resident #1 was administered supplemental oxygen via nasal cannula, Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) without a physician's order. These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. Findings included: Record review of Resident #1's face sheet, dated 05/13/2025, indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial skin infection that can cause pain, redness, swelling, and warmth in the affected area), peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain), congestive heart failure (a condition where the heart muscle is unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an adequate communication system to allow residents to call for staff assistance for 1 of 6 rooms (Room # 1's room) on the PCC hallway reviewed for an operating call light system. The facility failed to ensure Resident #1's room had an operating call light system. This deficient practice could place residents at-risk of not being able to call for staff assistance to meet care needs. The findings include: Record review of (Resident #1's) face sheet, dated 1/22/25, revealed an admission date of 3/5/24 for the [AGE] year male with diagnoses which included: type 2 diabetes( a condition in which the body does not control blood sugar), essential hypertension( a condition in which high blood pressure develops), and unspecified gout (a painful form of arthritis). Record review of (Resident #1's) Quarterly MDS assessment, dated 11/29/24, revealed the resident had a BIMS score of 13, which indicated intact cognition. Resident #1 needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 (West Hall Downstairs) of 4 resident hallways reviewed for environmental concerns. On [NAME] Hallway Downstairs- the facility failed to repair the overhead 5x2 ft light in the unmarked resident shower room on the right side of the resident hallway between resident rooms [ROOM NUMBERS] which was not operable and the overhead 1 ft circular ceiling heater in the unmarked resident shower room on the left side of the resident hallway between rooms [ROOM NUMBERS] was not operable. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant and unsafe. The findings included: During an observation on 01/22/25 from 10:20 a.m to 10:30 a.m. with the Maintenance Director and the Assistant Director of Nurses(ADON-A) revealed the following: a- in the unmarked resident shower…

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 under sanitary conditions in accordance with professional standards for food safety in the facility kitchen. 1) CNA A failed to put on a hair net before entering the facility kitchen. This failure could place residents receiving food from the facility kitchen at risk for cross contamination. The findings included: During an observation on 08/08/2024 at 9:45 a.m., no hair nets were observed in the wall mounted container labeled hair nets on the outside of the facility kitchen entrance. During an observation during kitchen rounds on, 08/08/2024 at 9:50 a.m., CNA A was observed entering the kitchen and walking approximately 4 feet to the ice machine without a hair net covering her hair. Dietary Aide A was observed approaching CNA A and asked her to leave the kitchen. During an interview with the Dietary Manager on, 08/08/2024 at 9:52 a.m., the Dietary Manager stated it was mandatory for all employees to wear a hair net in the kitchen. The Dietary Manager said 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 interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than 2 hours after the allegation was made to the State agency for 1 of 7 staff (Resident #1) reviewed for failure to report. in that: 1. CNA B did not report an allegation of abuse at the time of the suspected abuse for Resident #1 on 05/31/2024. 2. CNA C did not report an allegation of abuse at the time of the suspected abuse for Resident #1 on 05/31/2024. This failure could place residents at risk of abuse or neglect. Findings included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes (a condition resulting from insufficient production of insulin, causing high blood sugar), depression, and anxiety. Record review of Resident #1's annual MDS, dated [DATE], revealed Resident #1 had a BIMS…

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 observations, interviews, 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, in that: 1. There were 10 slices of bread in the refrigerator that were not labeled or dated. 2. There was a box of 400 coffee creamers in the refrigerator that were not labeled or dated. 3. An ice cream freezer had an internal temperature of 70 degrees with 20 4 -ounce packets of melted ice cream. 4. A bag of 12 waffles in an outside freezer was not labeled or dated. 5. Three boxes of 3-gallon containers of apple juice concentrates in the storeroom were not labeled or dated. 6. The ceiling vent across from the dish machine had dirt and grease on the vent slats. 7. A Dietary Aide, DA D was observed in the kitchen not wearing a hair restraint. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance,…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 (Main Dining Room) of 2 dining rooms reviewed and 1 (Hall 100) of 5 hallways reviewed for pests, in that: 1. Numerous flies were observed in a resident room on Hall 100. 2. Numerous flies were observed near a trash can and on Resident #53's food and drink in the Main Dining Room. This deficient practice could place residents at risk of residing in an environment with pests. The findings were: 1. Observation on 04/23/2024 at 10:30 a.m. revealed the presence of numerous flies in Resident #46's room on Hall 100. During an interview with Resident #46, at the same time as the observation, Resident #46 stated flies were in his room daily, often land on him, and stated, They drive me crazy. 2. Observation on 04/23/2024 at 12:50 p.m. revealed the presence of flies in and around a large trash can in the Main Dining Room. Further observation at 12:57 p.m. revealed flies landed on Resident #53's food and drink in the Main Dining Room. During an attempted interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 4 of 8 residents (Residents #20, #8, #3, and #29 ) reviewed for care plans. The facility failed to invite and include the input of the resident (Resident #20, #8, #3, and #29 ) and/or residents' representatives as members of the interdisciplinary team in Care Plan Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or residents' representatives in Care Plan Conference meetings. The findings included: 1. Record review of the admission Record revealed Resident #20 was a [AGE] year-old female originally admitted on 7/09/2020. Record review of the comprehensive MDS dated [DATE], revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 30 residents (Residents #46, #53, and #85) reviewed for comprehensive person-centered care plans, in that: 1. Resident #46's care plan did not address the resident's broken and missing teeth. 2. Resident #53's care plan did not address the resident's diet, need for assistance with activities of daily living, or discharge plans, and contained incomplete sentences/incomplete care information. 3. Resident #85's care plan did not address the resident's diet, advance directive, wounds, medication, need for assistance with activities of daily living, specialized medical equipment, or discharge plans. This deficient practice could place residents at risk of illness or injury due inadequate care. The findings were: 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 (Resident #20) reviewed for quality of care in that: Resident #20 did not receive ordered weekly skin assessments between 2/23/2024 and 4/22/2024. This failure could place residents at risk of not receiving the necessary interventions to reach their highest practicable physical, mental, and psychosocial well-being. The findings included: Record review of the admission Record revealed Resident #20 was a [AGE] year-old female originally admitted on [DATE]. Record review of Resident #20's comprehensive MDS, dated [DATE], revealed the resident had a BIMS summary score of 2, indicative of severe cognitive impairment. Resident #20's primary medical condition category that best described the primary reason for admission was medically complex condition related…

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 the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 2 (Residents #68 and #87) of 30 residents, and in 1 of 5 hallways (Hall 100) reviewed for accident hazards, in that: 1. Resident #68 was observed with a package of cigarettes and a cigarette lighter in the facility dining room. 2. Resident #87 was observed with a package of cigarettes and utilizing a cigarette lighter and pair of scissors in the facility courtyard. 3. A storage room on Hall 100 was marked, Clean Linen was open and unlocked and contained bathing supplies including razors. 4. Shower room [ROOM NUMBER] on Hall 100 was open and unlocked and container bathing supplies including razors. This deficient practice could place residents at risk of injury due to accidents. The findings were: 1. Observation on 04/23/2024 at 12:48 p.m. revealed Resident #68 self-propelled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 4 of 4 residents (Residents #3, #12, #42, and #63) reviewed for oxygen, in that: 1. The facility failed to ensure orders were in place to manage Resident #3's supplemental oxygen support devices. 2. The facility failed to ensure oxygen humidifier bottles were changed for Residents #12, #42, and #63 when empty. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings were: 1. Record review of the admission Record revealed Resident #3 was a [AGE] year-old female. Resident #3 was original admitted on [DATE]. Record review of Resident #3's quarterly MDS assessment, dated 4/03/2024, revealed Resident #3 had a BIMS summary score of 14, indicative of intact cognition. Resident #3's primary medical condition category that best…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 residents' refrigerators (refrigerators in resident room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed in that: The personal refrigerators in residents' rooms [ROOM NUMBERS] contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled. The findings were: Observation on 04/23/2024 at 10:02 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] contained scrambled eggs with cactus, which was unlabeled and undated. Observation in room [ROOM NUMBER] on 04/24/2024 at 10:32 a.m. revealed a container with scrambled eggs and cactus was still present. During an interview with CNA B on 04/23/2024 at 10:35 a.m., CNA B confirmed that the personal refrigerator in resident room [ROOM NUMBER] contained a container with scrambled eggs and cactus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #2) reviewed for infection control, in that: The Sharps container in Resident # 2's room was overfilled. These deficient practices could place residents at risk for infection due to improper care practices. The findings include: Record review of Resident #2's face sheet dated 4/26/24, revealed a [AGE] year old female admitted to the facility on [DATE], with diagnosis which included: Diabetes mellitus (is a disease of inadequate control of blood levels of glucose, Cerebral arteriosclerosis (is a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque inside the artery walls) and cerebral infarction (appears as a result of disrupted blood flow to the…

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

Based on observation, interview, and record review, the facility failed to establish and enforce policies regarding smoking for 1 of 1 facility reviewed for smoking, in that: Residents #43, #198, and #199 were observed smoking in the facility courtyard and all stated that they kept their own cigarettes and lighters in their rooms. This failure could place residents at risk of dwelling within an unsafe smoking environment. The findings were: Observation on 04/23/2024 at 12:05 p.m. revealed Residents #43, #198, and #199 were smoking in the facility courtyard. During interviews with Residents #43, #198, and #199, at the same time as the observation, Residents #43, #198, and #199 each stated that they keep their cigarettes and cigarette lighters in their rooms. Record review of Residents #43, #198, and #199's smoking assessments revealed they all have been assessed as safe to smoke independently. During an interview with the Administrator on 04/25/2024 at 4:30 p.m., the Administrator stated that while some residents had been assessed to safely smoke independently, none were meant 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 interviews and record reviews the facility failed to develop, implement, and revise a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 33 residents (Residents #43 and #55) reviewed for care plans, in that: 1. The facility failed to include insulin administration on Resident #43's Care Plan. 2. The facility failed to revise a care plan to address Resident #55's insulin administration on the care plan dated 3/29/24. This failure could have placed residents at risk of not having their needs identified and met. The findings included: 1. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #43 was a [AGE] year-old male admitted on [DATE]. Resident #43 had a BIMS summary score of 11, indicative of moderate cognitive impairment. Resident #43 was coded as…

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

Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control in that: 1. There was no signage on the front door of the facility to let visitors know the facility was in outbreak mode due to COVID. 2. Staff of multiple disciplines (the SW, Agency LPN Z, LPN B, RN X) were not utilizing appropriate PPE while the facility was experiencing a COVID outbreak. These failures placed all residents at risk for the spread of infection through cross-contamination of pathogens and illness which could result in a decline in health and well-being or even death. Findings included: 1. Observation and interview with the receptionist on 02/06/24 at 09:15 AM revealed there was not a sign on the facility front door stating the facility had someone with active COVID. The receptionist stated they usually had a sign to let visitors…

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 with the necessary care and services to maintain good personal hygiene for 2 of 5 Residents (Residents #7 and #10) whose records were reviewed for ADL care. 1. Nursing staff failed to ensure Resident #7 received incontinent care for over 2 hours after she urinated and had an episode of diarrhea. 2. Nursing staff failed to ensure Resident #10 received incontinent care as needed for at least 6 hours during the morning shift. These deficient practices could affect residents who required assistance with toileting and could contribute to feelings of discomfort and skin break down. The findings were: 1. Review of Resident #7's face sheet, dated 2/8/24, revealed she was admitted into the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (characterized by high blood sugar, insulin resistance, and relative lack of insulin) without complications and other recurrent Depressive Disorders (classified as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medications for 19 of 49 residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #20, #11, #21) reviewed for pharmacy services, in that: The facility failed to ensure residents received medications as ordered by the physician for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #20, #11, and #21. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medication, resulting in worsening or exacerbation of chronic medical conditions, hospitalization, and/or death. The findings were: 1. Record review of Resident #2's admission Record, dated 02/09/24, reflected an original admission date of 08/30/19 with diagnoses that included chronic pain, conversion disorder (a mental condition that causes physical symptoms without a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 4 residents (Residents #1 and #2) reviewed for comprehensive care plans in that: 1. The facility failed to develop a plan of care to address Resident #1's multiple wounds. 2. The facility failed to develop a plan of care to address Resident #2's wounds. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: 1. Record review of Resident #1's face sheet dated 1/23/2024 revealed an admission date of 8/23/2016 with readmission date of 1/19/2024 with diagnoses which included: cerebral infarction, type 2…

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 2 of 4 residents (Residents #1 and #2) reviewed for accuracy of medical records in that: 1. The facility failed to ensure Resident #1's wound care was documented on the TAR for multiple dates in January. 2. The facility failed to ensure Resident #2's wound care was documented on the TAR for multiple dates in January. This deficient practice could affect residents whose records are maintained by the facility and could place improper identification of staff and role in the resident medical records. The findings included: 1. Record review of Resident #1's face sheet dated 1/23/2024 revealed an admission date of 8/23/2016 with readmission date of 1/19/2024 with diagnoses which included: cerebral infarction, type 2 diabetes mellitus and dementia. Record review of Resident #1's Care Plan initiated on 12/04/2023 and last…

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 implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 6 staff (Agency LVN A) reviewed for background screenings, in that: The facility had failed to ensure an Employee Misconduct Registry search was completed for Agency LVN A. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included: Record review of the Agency LVN A's agency personnel file revealed a criminal background check and EMR were completed in 11/2022. There was no evidence that a yearly EMR search had been completed since 2022. During an observation on 1/23/2024 at 8:15 a.m. Agency LVN A was observed behind the nurses' station on the north hallway. During an interview on 1/23/2024 at 1:40 p.m., Agency LVN A stated she was working for the facility for the second time. She stated she could not remember the date of the last time she worked before today (1/23/2024). She stated she was employed by a local staffing nursing…

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 be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for monitoring and implementing the facility policy and procedures for 1 of 1 facility reviewed for Administration. The facility failed to develop and implement a written policy for nursing student. The facility failed to supervise and provide oversight to nursing students and their instructor. These deficient practices could place residents at risk for infection. The findings included: Record review of Resident #1's face sheet dated 1/23/2024 revealed an admission date of 8/23/2016 with readmission date of 1/19/2024 with diagnoses which included: cerebral infarction, type 2 diabetes mellitus and dementia. Record review of Resident #1's Care Plan initiated on 12/04/2023 and last revised on 12/13/2023 revealed Resident #1 had impaired skin integrity related to DTI to left inner foot with no plan 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control, in that: The facility failed to ensure Resident #1 received wound care to her left heel DTI using appropriate hand hygiene and infection control principles. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health. The findings were: Record review of Resident #1's face sheet dated 1/23/2024 revealed an admission date of 8/23/2016 with readmission date of 1/19/2024 with diagnoses which included: cerebral infarction, type 2 diabetes mellitus and dementia. Record review of Resident #1's Care Plan initiated on 12/04/2023 and last revised on 12/13/2023 revealed Resident #1 had impaired skin…

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 refer all Level II residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 5 Residents (Resident #9) reviewed for PASSAR services. The MDS Coordinator failed to refer Resident #9 for a resident review after being diagnosed with bipolar disorder current episode manic severe with psychotic features and Manic depressive disorder. The onset of both diagnoses was during 2021. This deficient practice could place residents at risk of not receiving the needed PASSAR services. The findings were: Review of Resident #9's face sheet, dated 3/9/23, revealed he was admitted to the facility on [DATE] with diagnoses including bipolar disorder current episode manic severe with psychotic features (psychiatric disorder in which the principal feature is mood disturbance) and diffuse traumatic brain injury without loss of consciousness (most…

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 residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental, and psychosocial needs for 5 of 17 residents (Residents #6, #8, #34, #44 & # 65) reviewed for care plans. 1. Resident #6's comprehensive care plan did not address the resident's use of scheduled pain medication. 2. Resident #8's comprehensive care plan did not address the resident's multiple missing teeth. 3. Resident #34's comprehensive care plan did not address the resident receiving rehabilitation services. 4. Resident #44's comprehensive care plan did not address the resident's behavior of leaving the facility independently in his electric wheelchair. 5. Resident #65's comprehensive care plan did not address that the resdient has a G-tube in place. These deficient practices could place residents at risk of receiving inadequate…

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 based on the comprehensive assessment of a resident, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident choices for 3 of 3 residents (Resident #59, #64 and #80) reviewed for quality of care. The facility failed to accurately assess and develop care plans for Residents #59, #64, and #80 for the residents' use of pacemakers, and did not complete daily checks for the residents' pacemakers. These deficient practices could place residents at risk of cardiac complications or pacemaker malfunctioning due lack of treatment and services. The findings were: 1. Record review of Resident #59' s face sheet, a [AGE] year old female, dated 3/10/2023, revealed an admission date of 12/13/2017 with diagnoses which included: hypothyroidism (the thyroid gland can't make enough thyroid hormone to keep the body running normally), morbid obesity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident #14) reviewed for oxygen care. Nursing staff did not ensure Resident #14 received 3 liters of oxygen per physician orders for at least 3 days. This deficient practice could place residents at risk for experiencing breathing complications. The findings were: 1. Review of Resident #14's face sheet, dated 3/10/23, revealed she was admitted to the facility on [DATE] with diagnoses including seizure disorder (episodes of uncontrolled electrical activity in the brain), neuralgia (severe pain due to damaged nerves that causes severe burning pain) and neuritis (inflammation of one or more nerves) unspecified and personal history of other infectious (of a disease or disease-causing organism) and parasitic…

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 assessments accurately reflected the resident's status for 1 of 6 Residents (Resident #8) reviewed for assessments. MDS Coordinator did not code that Resident #8 had missing teeth on her admission assessment. This deficient practice could place residents at risk of not receiving needed services. The findings were: Review of Resident #8's face sheet, dated 3/2/23, revealed she was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (a type of dementia that damages the brain and affects memory, thinking, and behavior). Review of Resident #8's admission MDS, dated [DATE], revealed Resident #8's BIMS was 0 (out of 15) which was indicative of severe cognitive impairment. She required extensive assistance by 1 staff for eating and the oral/dental status reflected Resident #8 did not have dental problems. Review of Resident #8's Care Plan, dated 2/8/23, revealed she required limited assistance by 1 staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 6 Residents (Resident #8) reviewed for adl care. Nursing staff failed to ensure Resident #8 was assisted with feeding during a lunch meal. This deficient practice could place residents at risk of experiencing a decline in their physical condition. The findings were: Review of Resident #8's face sheet, dated 3/2/23, revealed she was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (a type of dementia that damages the brain and affects memory, thinking, and behavior). Review of Resident #8's admission MDS, dated [DATE], revealed Resident #8's BIMS was 0 (out of 15) which was indicative of severe cognitive impairment. She required extensive assistance by 1 staff for eating and the oral/dental status reflected Resident #8 did not have dental problems. Review of Resident #8'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.