Norfolk Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure an enhanced barrier precaution sign was posted for 1 resident to prevent the spread of infection for 1 of 28 residents (Resident # 117), in the survey sample.The findings included: Resident #117 was originally admitted to the facility 10/23/25 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Tracheostomy Status. The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/17/25 coded the resident as having short-term memory loss which indicated Resident #117 cognitive abilities for daily decision making were moderately impaired. Section K (Swallowing/Nutritional Status) coded the resident as having a Feeding Tube. A review of the Physician's order Summary for December 2025 read Enhanced Precaution r/t Trach every shift. Active from 11/04/25. On 1/13/26 and during the initial tour of the facility at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to maintain a sanitary and comfortable environment for all.The findings included: 1. The facility staff failed to provide a sanitary and comfortable environment in the 200-unit. On 1/12/25, it took 12 minutes from the time the call button was activated until the elevator arrived at the front lobby. Upon arriving at the 200's unit on 1/12/24 at approximately 3:30 PM, the lower numeral corridor was observed to be littered with debris on the floor, had many dark spots on the floor that appeared to be uncleaned spills, and the corridor was cluttered with various medical equipment. In room [ROOM NUMBER], the floor was simply dirty, the trash can was without a liner, and a used glove was observed on the floor. The A bed resident had mats at the bedside with holes and a dark substance on them. Under the head of the bed, the floor space was filled with broken, useless items, a wheelchair leg rest, and 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, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide timely incontinence care after each episode for 1 of 5 residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility on [DATE]. The current diagnoses included hypertension (HTN), congestive heart failure (CHF), Diabetes Mellitus (DM), Arthritis, and Anxiety. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/10/24 coded Resident #1 as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15, indicating Resident #1 cognitive abilities for daily decision making were intact. In section H(Bladder and Bowels) Resident #1 was coded as always incontinent of bladder and frequently incontinent of bowels. In section M(Skin Conditions) the resident was noted to be at risk for pressure ulcers and received ointment application to 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 general observations of the facility, staff and resident interviews, the facility staff failed to maintain an effective pest control program. Roaches were identified during the survey and recorded sightings by staff on all four floors (three resident units and first floor kitchen and common areas). The findings included: The pest sighting log sheets on all four floors identified roaches. Specifically, a review of the last 6 months on the first floor revealed roaches inside the dietary food cart, baseboard dish room, food tray and activities depart. A review of the last 6 months on the second floor revealed roaches in general areas, room [ROOM NUMBER], 227, soiled utility room and roaches everywhere in hallway. A review of the last 6 months on the third floor revealed roaches in room [ROOM NUMBER], 302, 303, 304, 307, 312, 314, 321, 324, 325, 327 and 331 identified by residents and staff. A review of the last 6 months on the fourth floor revealed roaches on the walls, ceiling, floor and hallways and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility documentation, the facility staff failed to ensure that 3 of 56 residents (Resident #71, Resident #141 and Resident #129) in the survey sample received a complete and accurate assessment. The findings included: 1. The facility staff failed to ensure the Quarterly MDS with an Assessment Reference Date (ARD) of 05/19/21 under Section P for the use of Restraints and Alarms was coded correctly for Resident #71. Resident #71 was admitted to the nursing facility on 11/29/16. Diagnosis for Resident #71 included but not limited to muscle weakness. Resident #71's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 05/19/21 coded Resident #71's Brief Interview for Mental Status (BIMS) scored an 11 out of a possible score of 15 indicating moderate cognitive impairment. In addition, the MDS coded Resident #71 total dependence of one with bathing, extensive assistance of two with bed mobility, transfer, toilet use and personal…

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, clinical record review, staff and resident interviews, the facility staff failed to ensure 8 of 56 (Residents #119, #239, #114, #106, #129, #126, #60 #22) residents grooming and personal hygiene needs were met. The findings included: 1. Resident #119 was admitted to the nursing facility on 6/14/21 with diagnoses that included osteomyelitis of the vertebra, lumbar region and on intravenous antibiotics. The most recent Minimum Data Set (MDS) assessment was an admission dated 6/20/21 and coded Resident #119 on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated the resident was cognitively intact in the skills for daily decision making. The resident was assessed to require extensive assistance of two staff for bathing/showers. The resident was coded only able to stabilize himself with staff assistance. Resident #119 had no impairment in upper extremities, but possessed impairment in bilateral lower extremities. On 7/13/21 at 11:00…

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 staff interviews, clinical record review and facility documentation review the facility staff failed to ensure for 1 of 56 residents in the survey sample, Resident #442 received Gabapentin medication as ordered. The findings included: Resident #442 was originally admitted to the facility on [DATE]. Resident #442 was discharged to the hospital on 3/26/2021 and readmitted to the facility on [DATE]. Resident #442 was discharged to the hospital on 5/8/2021. Diagnoses included but were not limited to, Type 2 Diabetes Mellitus with Hyperglycemia and Major Depressive Disorder. Resident #442's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 04/08/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #442 as requiring supervision with setup help only for eating, extensive assistance of 1 with dressing and personal hygiene, extensive assistance of 2 with bed mobility, total…

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 information obtained during the Resident Council Meeting, and interviews, the facility staff failed to inform residents of where State licensing Agency contact information was posted to include email, addresses and phone numbers. The findings included: A resident council meeting was held in the resident dining hall on 7/14/21 at approximately, 11:00 AM. Five residents attended the meeting. The residents were not aware of how to obtain or utilize the Long-Term Care Ombudsman's contact information or other advocacy agencies. They also was not aware of where the signage was located. On 7/14/21 at approximately 11:48 AM an interview was conducted with the Activity Director (OSM/Other Staff Member #4) regarding the residents in the Resident Council Meeting stating they didn't know where to find the Ombudsman contact information. The Activity Director stated, They say the same thing every year. We go over who's the ombudsman. We have gone over it several times. The above findings were shared with the Director of Nursing and the Corporate Nurse on 7/15/21 at approximately 2:19 PM…

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 staff interview, facility documentation review and clinical record review the facility staff failed to ensure for 1 of 56 residents in the survey sample, Resident #121, was provided an opportunity to formulate an advanced directive. The findings included: Resident #121 was originally admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses for Resident #121 included but are not limited to, Type 2 Diabetes Mellitus with Diabetic Neuropathy and Anxiety Disorder. Resident #121's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 06/23/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #121 as requiring extensive assistance of 2 for bed mobility and dressing, total dependence of 1 with toilet use and independent with setup help only for eating and personal hygiene. On 07/14/2021 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 record review and staff interviews the facility staff failed to provide one resident (Resident #189) in the survey sample of 56 residents with documentation of a comprehensive care plan goals during discharge/transfer to a hospital. The findings included: Resident #189 was admitted to the facility with diagnoses which included end stage renal disease, chronic kidney disease, benign neoplasm of pituitary gland, cannabis abuse, obstructive sleep apnea, renal dialysis, mental disorder and hypertension. The facility staff failed to provide documentation of a comprehensive care plan goals when transferred/discharged to the hospital. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns Basic Information for Mental Status (BIMS) as a level 15. In the area of Activities of Daily Living (ADL's) this resident was coded as a 2/2 for mobility, requiring one person assist. In the area of Transfer this resident was coded as 2/3, requiring a two person physical…

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 resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 56 residents (Resident #60 and Resident #189) in the survey sample. The findings included: 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #60's transfer and admission to the hospital on [DATE]. Resident #60 was originally admitted to the nursing facility on 07/09/19. Diagnosis for Resident #60 included but not limited Type II Diabetes. Resident #60's Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 05/18/21 coded Resident #60's Brief Interview for Mental Status (BIMS) scored a 15 out of a possible score of 15 indicating no cognitive impairment. The Discharge MDS assessments was dated for 05/10/21 - discharged with return anticipated. On 5/10/21, according to the facility's documentation, Resident #60…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility staff failed to provide one resident (Resident #189) in the survey sample of 56 residents with a notice of Bed Hold Policy before being transferred to the hospital. The findings included: Resident #189 was admitted to the facility with diagnoses which included end stage renal disease, chronic kidney disease, benign neoplasm of pituitary gland, cannabis abuse, obstructive sleep apnea, renal dialysis, mental disorder and hypertension. The facility staff failed to provide a notice of the facility's Bed Hold Policy prior to being transferred to the hospital. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns Basic Information for Mental Status (BIMS) as a level 15. In the area of Activities of Daily Living (ADL's) this resident was coded as a 2/2 for mobility, requiring one person assist. In the area of Transfer this resident was coded as 2/3, requiring a two person physical assist. In the area of Dressing…

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 resident interview, staff interview, and clinical record review the facility's staff failed to develop a person-centered comprehensive care plan to include use of an indwelling catheter for 1 of 56 residents (Resident #126), in the survey sample. The findings included: Resident #126 was originally admitted to the facility 6/17/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; renal and perinephric abscesses and ureteral calculous obstruction. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/23/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #126 cognitive abilities for daily decision making were intact. In section H0100 of the MDS assessment the resident was coded for utilizing an indwelling catheter. During the initial tour on 7/13/21, Resident #126 was observed with a catheter drainage bag attached to the bedframe. Resident #126 stated he was hospitalized 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.

Based on resident interview, staff interview, and clinical record review the facility's staff failed to obtain a physician's order for use of an indwelling catheter for 1 of 56 residents (Resident #126), in the survey sample. The findings included: Resident #126 was originally admitted to the facility 6/17/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; renal and perinephric abscesses and ureteral calculous obstruction. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/23/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #126 cognitive abilities for daily decision making were intact. In section H0100 of the MDS assessment the resident was coded for utilizing an indwelling catheter. During the initial tour on 7/13/21, Resident #126 was observed with a catheter drainage bag attached to the bedframe. Resident #126 stated he was hospitalized for what he thought was an…

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, resident interview, staff interview, and clinical record review the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce complications while utilizing an indwelling catheter for 1 of 56 residents (Resident #114), in the survey sample. The findings included: Resident #114 was originally admitted to the facility 6/9/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; obstructive uropathy, benign prostatic hyperplasia and urinary retention. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/15/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #114 cognitive abilities for daily decision making were intact. In section H0100 of the MDS assessment the resident was coded for utilizing an indwelling catheter. During rounds on 7/13/21 at approximately 11:25 a.m., Resident #114 stated he had experienced kidney problems…

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 information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The facility staff failed to staff a RN for at least 8 consecutive hours a day on 10/7/17, 10/21/17 and 10/22/17. This affects all residents. The findings included: During the nursing staff review for September 1, 2017 through May 8, 2019 the facility staff was unable to verify RN presence in the facility for at least 8 consecutive hours on 10/7/17, 10/21/17 and 10/22/17, therefore; further verification was requested. On 5/9/19 at approximately 5:00 p.m., the Corporate Consultant stated they were unable to present any information verifying a RN was present in the facility for 8 consecutive hours on 10/7/17, 10/21/17 and 10/22/17. The above findings were shared with the Administrator, Director of Nursing and the Corporate Consultant on 5/9/19 at approximately 5:10 p.m., the Corporate Consultant stated they didn't want to address the concern any further. The facility's policy titled…

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 staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their care plan goals after being discharged /transferred to the hospital for 3 of 60 residents (Resident #52, 51 and 3) in the survey sample. 1. The facility staff failed to send Resident #52's Care Plan Summary to include goals when discharged to the hospital on [DATE]. 2a. The facility staff failed to convey to the receiving provider Resident #51's comprehensive care plan goals at the time of discharge to the local hospital on [DATE]. 2b. The facility staff failed to convey to the receiving provider Resident #51's comprehensive care plan goals at the time of discharge to the local hospital on 2/7/19. 3. Facility staff failed to evidence that all the required documentation; care plan goals were sent with the resident at the time of a facility-initiated transfer for Resident #3. The findings included: 1. The facility staff failed to send 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 staff interviews, clinical record review and facility documentation review the facility staff failed send a copy of the Bed-Hold Policy for 5 of 60 residents (Resident #52, 79, 51, 55 and 3) after being transferred to and admitted to the hospital. 1. The facility staff failed to ensure that Resident #52 was provided a written copy of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE]. 2. The facility failed to provide Resident #79 with a written notice of the facility's Bed-Hold Policy upon transfer to the hospital 4/17/19. 3. The facility staff failed to ensure Resident #51 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on [DATE] and 2/7/19. 4. The facility staff failed to ensure that Resident #55 received a written notice of the facility Bed-Hold policy upon transfer to the hospital on [DATE]. 5. For Resident #3, facility staff failed to evidence that written bed hold…

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, staff interview, and facility documentation review, the facility staff failed to dispose of controlled medications in a secure and safe method to prevent diversion and/or accidental exposure upon inspection of 1 out of 3 medication carts. The findings include: On 5/8/19 at 11:20 a.m., during inspection of a medication cart, the narcotic count for *oxycodone 5 milligrams (mg) was short 1 tablet. Upon inspection with the Licensed Practical Nurse (LPN) #7 the count was 9 tablets of oxycodone, but the narcotic sign out sheet recorded 10 on 5/8/19 at 9:00 a.m. LPN #7 stated she dropped the tablet and was going to have (name of Assistant Director of Nursing) waste the tablet with her. She did not respond when asked what she did with the oxycodone tablet. *Oxycodone, a class II narcotic, is a semisynthetic derivative of codeine that acts as a narcotic analgesic more potent and addicting than codeine. (https://www.drugbank.ca/drugs/DB00497) On 5/8/19 at 11:30 a.m., the ADON stated she did not know about LPN #7 dropping the narcotic, but she could have asked any…

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 information obtained during the Resident Council Meeting, observations and interviews, the facility staff failed to respond to ongoing resident issues. The findings included: The Surveyor received 6 months of resident council meeting minutes from the Activity Director. The following were ongoing concerns for six months: On 12/11/18 Residents complained of (c/o) call bells not being answered. On 11/13/18 Residents c/o cold foods, and call bells not being answered. On 1/08/19 Residents c/o cold foods, and call bells not being answered. On 2/12/19 Residents c/o cold foods, and call bells not being answered. On 3/12/19 call bells not being answered. On 4/9/19 ongoing issues, cold foods, call bells not being answered and not getting snacks. On 05/08/19 at approximately 1:14 PM a Resident Council meeting was held in the Resident dining room at the facility. There were eleven Resident's present. An interview was conducted with the residents. The following questions were asked concerning grievances. 1. Does the Grievance Official respond to the resident or the family groups? 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 resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 1 of 60 residents (Resident #52) in the survey sample. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #52's transfer to the hospital on [DATE]. The findings included: Resident #52 was originally admitted to the facility on [DATE]. The resident was readmitted on [DATE]. Diagnosis for Resident #52 included but not limited to Cardiomyopathy. The current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/19 coded Resident #52 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long-term memory problems and with severe cognitive impairment - never/rarely made decisions. The Discharge MDS assessments dated 03/20/19 - discharge return anticipated, resident readmitted on [DATE]. On 03/20/19 at approximately 5:54 a.m., according 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 clinical record review, staff interviews, and review of the facility's policy the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 60 residents (Resident #92), in the survey sample. The facility staff failed to code hearing and vision loss in section B0200 and B1000 and hospice services in section O0100K2 of Resident #92's 4/1/19 quarterly MDS assessment. The findings included; Resident #92 was admitted to the facility 12/1/15 and was discharged from the facility to a local acute care hospital 6/22/18 and returned 6/25/18. The current diagnoses include; legal blindness, bilateral hearing loss and dementia. The quarterly MDS assessment with an assessment reference date (ARD) of 4/1/19 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. The facility's policy titled Minimum Data Assessment dated 9/15/16 read; at #7. Each person entering data into the MDS will…

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 clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure the baseline care plan summary was provided for 1 out of 60 residents (Resident #453) in the survey sample. The facility staff failed to issue a newly admitted resident, (Resident #453), a copy of the care plan summary. The summary must include the initial goals for the resident, a list of current medications and dietary instructions and services and treatments to be administered by the facility. The findings included: Resident #453 was admitted to the nursing facility on 05/03/19. Resident #453 diagnosis included but not limited to Pulmonary Fibrosis, hypoxia, Anxiety and Congestive Heart Failure. The resident's Minimum Data Set (MDS) assessment was not due. During the initial on 05/07/19 at approximately 12:07 p.m. Resident #453 was asked if she received a written care plan summary and if so did anyone explain the summary to her. She said as far as I know, no one has given me anything. The resident stated, I came here from the hospital but no one has…

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, resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to implement the comprehensive care plan for one of 60 residents in the survey sample, Resident #31. Facility staff failed to implement the comprehensive care plan and ensure Resident #31's environment was free from fall hazards. The findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease (1), schizophrenia, and muscle weakness. Resident #31's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 2/22/19. Resident #31 was coded as being cognitively intact in the ability to make daily decisions scoring 14 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #31 was coded in section G (Functional Status) as being able to walk independently in his room. On 5/9/19 at 10:00 a.m., an…

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 resident interview, staff interview, clinical record review and review of the facility's policy the facility staff failed to assure the person centered plan of care was revised as the resident's status changed for 1 of 60 residents, (Resident #79) in the survey sample. The facility staff failed to revise Resident #79's care plan after a fall to reduce the likelihood of another fall. The findings included; Resident #79 was originally admitted to the facility 10/11/13, and was readmitted to the facility 4/22/19, after an acute care hospital stay. The current diagnoses included; stroke with left hemiparesis, and seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/23/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15. This indicated Resident #79's daily decision making abilities were intact. In section G (Physical functioning) the resident was coded as requiring total care of one with bathing, extensive assistance of one with bed mobility, transfers, dressing,…

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 clinical record review, staff interviews, and review of the facility's policy the facility staff failed to provide care and services to maintain the resident's highest physical well-being for 1 of 60 residents (Resident #92), in the survey sample. The facility staff failed to follow the physician's order dated 6/29/18 and the person centered-care plan for, no weights for Resident #92. The findings included: Resident #92 was admitted to the facility 12/1/15 and was discharged from the facility to a local acute care hospital 6/22/18 and returned 6/25/18. The current diagnoses include; legal blindness, bilateral hearing loss and dementia. The quarterly MDS assessment with an assessment reference date (ARD) of 4/1/19 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. In section G (physical functioning) the resident was coded as requiring total care with bathing, personal hygiene, and toilet use,…

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 2. The facility staff failed to provide fingernail care for Resident #74, prior to his fingernails becoming long and with broken sharp edges. Resident #74 was originally admitted to the facility 11/24/17 and has never been discharged from the facility. The current diagnoses included; stroke, difficulty speaking, and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/22/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of 15. This indicated Resident #74's daily decision making abilities were severely impaired. The resident was coded in section G (Physical functioning) as requiring total care of one with bathing and off unit locomotion, extensive assistance of 2 people with transfers and extensive assistance of one with eating, toileting, bed mobility, on unit locomotion, dressing, and personal hygiene. Resident #74 was observed seated in the dining room awaiting the lunch meal. His fingernails were observed to be…

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 information gleamed during a complaint investigation, resident interviews, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to provide an environment which is free from accident hazards and elopement by implementing interventions and supervision for 3 of 60 resident in the survey sample, (Resident #79, 553 and 31). 1. The facility staff failed to identify Resident #79's inability to hold her leg/foot up for prolonged periods while being propelled in a wheel chair; which resulted in an avoidable fall. 2. The facility staff failed to provide necessary supervision to Resident #553 to prevent elopement from the facility. 3. The facility staff failed to ensure Resident #31's bathroom was free from fall hazards. The findings included; 1. The facility staff failed to identify Resident #79's inability to hold her leg/foot up for prolonged periods while being propelled in a wheel chair; which resulted in an avoidable fall. Resident #79 was originally…

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, resident interview, staff interviews, clinical record review, facility documentation review, the facility staff failed to provide 1 of 60 residents (Resident #453) in the survey sample with Respiratory care in accordance with professional standards of practice. The facility staff failed to ensure Resident #453's oxygen order contained a prescribed flow rate to be administered. The findings included: Resident #453 was admitted to the nursing facility on 05/03/19. Resident #453 diagnosis included but not limited to Pulmonary Fibrosis, hypoxia, Anxiety and Congestive Heart Failure. The resident's Minimum Data Set (MDS) assessment was not due. Resident #453's Interim care plan documented resident on oxygen therapy related to respiratory distress. The goal: Resident will have no signs of distress or poor oxygen absorption. Some of the intervention/approaches to manage goal included but not limited to give medications as ordered by physician and monitor for signs and symptoms of respiratory distress and report to physician as needed. During the initial on 05/07/19 at…

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

Based on clinical record review, staff interviews, and review of the Hospice policy; the facility staff failed to integrate the Hospice Agency's written agreement describing the responsibilities between the hospice agency and the nursing home for 1 of 60 residents (Resident #92), in the survey sample. The facility staff failed to ensure the Hospice Agency's coordinated plan of care for Resident #92, to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency was integrated with the facility's care plan. The findings included: Resident #92 was admitted to the facility 12/1/15 and was discharged from the facility to a local acute care hospital 6/22/18 and returned 6/25/18. The current diagnoses include; legal blindness, bilateral hearing loss and dementia. The quarterly MDS assessment with an assessment reference date (ARD) of 4/1/19 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff…

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, medical record review, facility documentation review, and staff interview the facility staff failed to ensure infection control measures were provided during wound care and the facility staff failed to conduct a risk assessment to reduce the risk of Legionella on 1 residents. (Resident #55) of 60 residents in the survey sample. For Resident #55, the facility staff failed to place a barrier under the Resident's Right Lower Extremity (right heel) while providing wound care and to sanitize equipment used in wound care (scissors and bedside table). The findings included: Resident #55 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnosis for Resident #55 included but not limited to Pressure Ulcer of Unspecified, Pressure Ulcer of Right Hip, and Major Depressive Disorder. The current Minimum Data Set (MDS), a discharged assessment with an Assessment Reference Date (ARD) of 02/19/19. Staff assessment of mental status coded the resident as having short term…

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, staff interview, clinical record review and facility document review the facility staff failed to provide the necessary care and services to promote and maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 25 residents in the survey sample (Residents #2 and #6). 1. The facility failed to obtain a Physician Order to cleanse a traumatic wound with Normal Saline and to apply a clean dressing for Resident #2. 2. The facility staff failed to identify two staples remaining in Resident #6's healed surgical sacral suture line. The Findings included: 1. Resident #2 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #2 included but not limited to Non Alzheimer's Dementia and Traumatic open wound to the Right heel. Resident #2's Annual Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date (ARD) of 6/3/17, coded Resident #2 with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and facility documentation the facility staff failed to administer two (2) significant medications for 1 out of 25 residents in the survey sample, (Resident #20). The facility staff failed to transcribe and administer 3 doses of Clonidine (1) and 7 doses of Methyldopa (2) (Hypertensive medications) as ordered by the cardiologist. The findings included: Resident #20 was admitted to the facility on [DATE]. Diagnosis for Resident #20 included but not limited to Hypertension (3). The current Minimum Data Set (MDS) a comprehensive assessment with an Assessment Reference Date (ARD) of 06/23/17 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), no cognitive impairment. In addition, the MDS coded Resident #20 for being independent with no assistance required for all ADL's (Activities of Daily Living) except eating requiring set-up help only. Resident was also coded as being continent of bowel 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, staff interview, and facility document review, the facility staff failed to maintain the proper food temperature at one of 3 nursing units. The facility staff failed to maintain the proper temperature for hot foods at 135 degrees Fahrenheit (F) or above at one of the nursing units, Unit 2. The findings included: During a Group Interview conducted on 08/16/17 at 10:00 AM with 11 cognitive residents, 6 residents out of the group stated the hot food was never hot because the food carts will sit on the floor about 15-20 minutes, if not longer, before the CNAs (Certified Nurse Aide) come to pass out the trays. Three (3) of the residents stated, I come from the 3rd unit and they won't even take the time to use the steam tables. On 8/16/17 at 11:50 AM, food temperatures were checked when the food arrived on Unit 2 after they were placed on the steam table. The temperature of the hot foods that were served was as follows: baked ziti was 110 degrees F and the broccoli was 130 degrees F. On 8/17/17 at approximately 4:20 PM, the Director of Food Services was interviewed…

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 resident interview, staff interviews, and clinical record review, the facility staff failed to assist 1 of 25 residents (Resident #6), in the survey sample to arrange dental services. The facility staff failed to assist Resident #6 to have his broken lower denture repaired or replaced. The findings included: Resident #6 was originally admitted to the facility 2/27/17 and has not been discharged from the facility. The current diagnoses included; diabetes, hyperlipidemia, seizure disorder, sleep apnea and schizophrenia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/27/17 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 2 persons with bed mobility, dressing, toileting, and personal hygiene and total care of two persons with bathing. On 8/16/17 at 10:30 a.m., an interview was conducted…

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 resident interview, staff interviews, and clinical record review, the facility staff failed to promptly resolve a grievance for 1 of 25 residents (Resident #6), in the survey sample. The facility staff failed to resolve Resident #6's grievance to have his broken lower denture repaired or replaced. The findings included: Resident #6 was originally admitted to the facility 2/27/17 and has not been discharged from the facility. The current diagnoses included; diabetes, hyperlipidemia, seizure disorder, sleep apnea and schizophrenia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/27/17 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 2 persons with bed mobility, dressing, toileting, and personal hygiene and total care of two persons with bathing. On 8/16/17 at 10:30 a.m., an interview…

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

Based on observations, resident interview, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to provide care and services to identify new pressure injuries for 1 of 25 residents (Resident #6), in the survey sample. The facility staff failed to identify a new pressure ulcer to the base of Resident #6's neck and a change in the right lateral foot deep tissue injury to a stage 2 pressure injury. The findings included: Resident #6 was originally admitted to the facility 2/27/17 and has not been discharged from the facility. The current diagnoses included; diabetes, hyperlipidemia, seizure disorder, sleep apnea and schizophrenia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/27/17 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 2 persons 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.

Based on observation, staff interview, facility documentation review, clinical record review the facility staff failed to discard medication prior to the expiration date in 1 of three Medication Storage Rooms (Unit 2). The findings included: On 8/15/17 at approximately 2:30 p.m. the Medication Room on Unit 2, a bottle of Magic Mouthwash with an expiration date of 8/13/17 was observed. in the Refrigerator. LPN #3 stated on 8/15/17 at approximately 2:30 p.m., Yes, it's expired. I will get rid of it. The Mayo Clinic documents: Magic Mouthwash is the term given to a solution used to treat mouth sores (oral mucositis) caused by some forms of chemotherapy and radiation therapy. Oral mucositis can be extremely painful and can result in an inability to eat, speak or swallow. Magic mouthwash provides some relief. The Facility Policy and Procedure revised 10/31/16, titled, Policy: 4.1 Physician/Prescriber Authorization and Communication of Orders to Pharmacy did not document information related to disposal of expired medications. The facility administration was informed of the findings during…

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, resident interview, staff interview, facility documentation review, and clinical record review the facility failed to ensure infection control practices were maintained to prevent the potential development and transmission of infection during wound care for three of 25 Residents in the survey sample, Resident #1, #2, and #14. 1. For Resident #1 staff failed to ensure proper handwashing and provide a clean barrier field for supplies during wound care. 2. For Resident #2 staff failed to ensure proper handwashing and provide a clean barrier field for supplies during wound care. 3. For Resident #14 staff failed to ensure proper handwashing, maintain clean barrier field and prevent contamination of supplies during wound care. The findings included: 1. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to Healing Stage IV Community Acquired Pressure Ulcer (1). Resident #1's Quarterly Minimum Data Set (MDS - an assessment protocol) with an…

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, staff interview, clinical record review and facility document review, the facility staff failed to maintain an accurate medical record for 1 of 25 residents in the survey sample, Resident #14. The facility staff failed to accurately document a physician order of Cranberry capsule for Resident #14. It was ordered to be administered per gastronomy tube (G Tube) (1) but it was transcribed by the nurse to be administered by mouth. The findings included: Resident #14 was admitted to the facility on [DATE]. Diagnoses for Resident #14 included but not limited to, dementia (2), diabetes mellitus (3) and high blood pressure. The most recent Minimum Data Set with an assessment reference date of 6/20/17, coded Resident #14 with a score of 99 on the Brief Interview for Mental Status (BIMS), indicating the resident was unable to complete the interview and had severe impairment in cognitive skills for daily decision-making. Resident #14 was assessed as having a G Tube in place. On 8/16/17, a 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.