Belmont Bay Rehabilitation And Healthcare Center

Based on observation, staff interview, clinical record review, it was determined that the facility staff failed to follow the comprehensive care plan for three of 50 residents in the survey sample, Residents #73 (R73), R413 and R80. The findings include: 1.For R73, the facility staff failed to follow the comprehensive care plan to keep fingernails clean. R73 was admitted to the facility with diagnoses that included but were not limited to: hemiparesis (1) and hemiplegia (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/09/2024, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R73 was moderately impaired of cognition for making daily decisions. Under Section GG Functional Abilities and Goals. Subsection I. Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) it coded R73 as 01(zero-one)- Dependent - Helper does ALL of the effort. Resident does…

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, clinical record review, it was determined that the facility staff failed to provide ADL(activities of daily living) care for one of 50 residents in the survey sample, Resident #73 (R73). For R73, the facility staff failed to clean his fingernails. R73 was admitted to the facility with diagnoses that included but were not limited to: hemiparesis (1) and hemiplegia (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/09/2024, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R73 was moderately impaired of cognition for making daily decisions. Under Section GG Functional Abilities and Goals. Subsection I. Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) it coded R73 as 01(zero-one)- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or,…

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, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 50 residents in the survey sample, Resident #413. For (R413), the facility staff failed to maintain the oxygen flow rate at three liters per minute according to the physician's orders. R413 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). R413's MDS (minimum data set) assessment was in process at the time of the survey, therefore R413's data was not available. The facility's Admission/readmission Evaluation dated 05/24/2024 for R413 documented in part, A. Cognitive/Neurological. 1. Mental Status: a. Alert. 2. Oriented to: a. Person, b. Place, c. Time, d. Situation. On 06/04/2024 at approximately 8:12 a.m., an observation of R413revealed they were lying in bed receiving oxygen by nasal cannula. An observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two-and-a-half and three liters per minute. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for one of 50 residents in the survey sample; Resident #79. The findings include: For Resident #79, the facility staff failed to ensure an accurate clinical record. The facility staff developed a comprehensive care plan for a diagnosis of diabetes. The resident was not diabetic. A review of the admission MDS (Minimum Data Set) assessment dated [DATE] regarding the administration of insulin coded as the resident being on insulin, having received seven insulin injections during the seven day look back period. The resident was not on any prescribed insulin. In Section N - Medications, was documented, Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 7 for seven days. The next part, Insulin documented, Insulin injections -…

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, it was determined that the facility staff failed to follow infection control practices during the medication administration for one of six residents in the medication administration observation, Resident #32 (R32). For R32, the facility staff failed to dispose of medications that were spilled out onto the top of the medication cart and were administered. On 06/04/2024 at approximately at approximately 8:04 a.m., an observation of LPN (licensed practical nurse) #7 during the medication pass was conducted. Observations of PLN #7 revealed she removed six medication bubble packs for R32 from the middle drawer of the medication cart and placed them on top of the medication cart. After verifying then medications with the eMAR (electronic medication administration record), LPN #7 obtained a small plastic medication cup from the end of the medication cart and placed it in front her on the top of the medication cart next the stack of bubble packs for R32. LPN #7 dispensed one-50mg (milligram) pill of hydralazine (1) 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, it was determined that the facility staff failed to preserve resident dignity when serving meals in one of one facility kitchen. The facility staff served the 7/19/22 lunch meal on disposable Styrofoam containers for all residents, and gave disposable eating utensils to the final seven residents served from the tray line. The findings include: On 7/19/22 at 1:29 p.m., OSM (other staff member) #1, the dietary manager, was observed as he served all resident lunches from the tray line in the facility's only kitchen. OSM #1 served each and every meal on a disposable Styrofoam container. The food was placed on one side of the container, and the other side of the container was folded over to create a cover. Two stacks of facility dishware were observed in a dish cart adjacent to the tray line. Additionally, the last seven Styrofoam containers served were paired with disposable plastic eating utensils. OSM #1 stated: I don't know where the [stainless steel] forks are going. We just don't have enough for everybody. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to maintain confidentiality of residents' medical records for 4 of 33 residents in the survey sample, Residents #7, #88, #25 and #96. The findings include: 1. The facility staff failed to maintain confidentiality of Resident #7's (R7) durable DNR (do not resuscitate) order. The order was posted on the wall in R7's room. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], the resident's cognitive skills for daily decision making was coded as severely impaired. On [DATE] at 2:46 p.m., an observation of R7's room was conducted. The resident's durable DNR order was posted on the wall behind the resident's bed. The order documented R7's name, the date the form was signed and the following: I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when 4 out of 33 residents in the survey sample were transferred to the hospital; Residents #37, #40, #350 and #1. The findings include: 1. The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #37. Resident #37 was transferred to the hospital on 6/27/22. Resident #37 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, diabetes mellitus, heart failure and encephalopathy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of written RP (responsible party) and/or ombudsman notification was provided for 4 of 33 residents, Residents #37, #40, #29 and #1. The findings include: 1. The facility staff failed to evidence provision of written RP notification was provided for Resident #37. Resident #37 was transferred to the hospital on 6/27/22. Resident #37 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, diabetes mellitus, heart failure and encephalopathy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when 3 out of 33 residents in the survey sample were transferred to the hospital; Residents #37, #40 and #1. The findings include: 1. The facility staff failed to evidence provision of bed hold notification for Resident #37. Resident #37 was transferred to the hospital on 6/27/22. Resident #37 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, diabetes mellitus, heart failure and encephalopathy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance…

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, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for 6 of 33 residents in the survey sample, Residents #82, #88, #37, #25, #83 and #94. The findings include: 1. The facility staff failed to implement Resident #82's (R82) comprehensive care plan for weights per physician's order. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/30/22, the resident scored 9 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. R82's comprehensive care plan dated 10/2/18 documented, (R82) is at risk for alteration ineffective breathing patterns and cardiovascular status due to: CHF (congestive heart failure) .weights as ordered . A review of R82's clinical record revealed a physician's order dated 6/3/22 for daily weights. Further review of R82's clinical record only…

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 document review and clinical record review, the facility staff failed to provide care and services in accordance with professional standards of practice and comprehensive care plan for 4 of 33 residents in the survey sample, Residents #82, #88, #83 and #19. The findings include: 1. The facility staff failed to obtain Resident's #82 (R82) daily weights per the physician's orders. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/30/22, the resident scored 9 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. R82's comprehensive care plan dated 10/2/18 documented, (R82) is at risk for alteration ineffective breathing patterns and cardiovascular status due to: CHF (congestive heart failure) .weights as ordered . A review of R82's clinical record revealed a physician's order dated 6/3/22 for daily weights. Further 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 staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 33 residents in the survey sample, Resident #37. The findings include: The facility failed to provide communication to the dialysis facility for 7 of 13 visits in April 2022, 8 of 13 visits in May 2022, 3 of 10 visits in June 2022 and 3 of 5 visits in July 2022. Resident #37 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, diabetes mellitus, heart failure and encephalopathy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed…

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, it was determined the facility staff failed to maintain sufficient dietary staff to meet the needs of the residents at the lunch meal on 7/19/22 in one of one facility kitchens. There was insufficient staff from the dietary department working at lunch on 7/19/22, resulting in residents' not receiving lunch at a time compatible with community standards, and resulting in residents being served on disposable dishes. The findings include: On 7/19/22 at 11:24 a.m., initial observation of the kitchen revealed OSM (other staff member) #1, the dietary manager, washing dishes from breakfast in the facility dish room. On 7/19/22 at 12:49 p.m., OSM #2, the dietary manager from a sister facility, had arrived in the kitchen, and was encouraging OSM #1. When asked if lunch was being served on time, and at a time compatible to when residents would normally be served lunch in the community, she stated: No there's a delay. She stated she was not sure what time lunch would start. She stated the delay was due to lack of staffing. She…

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 observation, staff interview, and facility document review, it was determined that the facility staff failed to serve a meal at a time compatible with community standards in one of one facility kitchens. The facility staff did not begin to serve the lunch meal on 7/19/22 until 1:25 p.m. The final resident tray was not distributed until 2:30 p.m. The findings include: On 7/19/22 at 11:24 a.m., initial observation of the kitchen revealed OSM (other staff member) #1, the dietary manager, washing dishes from breakfast in the facility dish room. At this time, no cooked lunch items were visible in the ovens, steam table, or the steamer. On 7/19/22 at 12:49 p.m., a follow up observation was made of the kitchen. OSM #2, the dietary manager from a sister facility, had arrived in the kitchen, and was encouraging OSM #1 as he worked to prepare baked pasta, steamed broccoli, salad, bread, and pureed food for lunch. When asked if lunch was being served on time, and at a time compatible to when residents would normally be served lunch in the community, OSM #2 stated: No there's a delay. She…

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, it was determined that the facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens. The cook's refrigerator had two opened, unlabeled items. The stove top and convection oven were dirty. OSM (other staff member) #1, the dietary manager, failed to take the holding temperatures of hot, perishable foods on the tray lines prior to serving them on 7/19/22. Trays for individual resident meals were wet nesting, and a dietary staff member used the same drying towel to dry all of them. The findings include: On 7/19/22 at 11:24 a.m., initial observation of the kitchen revealed OSM (other staff member) #1, the dietary manager, washing dishes from breakfast in the facility dish room. Initial observation of the kitchen revealed a dirty stove top. The stove contained heavy amounts of debris on the stove top and in the wells of the burners. Some of the debris was burned on; some of the debris was greasy; some of the debris was composed of particles of old food; some of 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 staff interview and facility document review, it was determined that the facility staff failed to evidence required annual continuing education (in-service) hours for five of five CNA (certified nursing assistant) records reviewed, CNAs #2, #3, #4, #5, and #6. For CNAs #2, #3, #4, and #5, the facility provided no evidence of dementia training in the past year. For CNA #6, the facility provided no evidence of dementia or abuse training in the past year. The findings include: On 7/19/22 at 4:59 p.m., OSM (other staff member) #5, the human resources director, was given a list of five CNAs for whom evidence of annual continuing education (in-services) was needed. On 7/20/22 at 3:38 p.m., OSM #5 provided continuing education transcripts for CNAs #2, #3, #4, and #5. She did not provide any transcripts for CNA #6. For CNAs #2, #3, #4, and #5, there was no evidence of any annual training in dementia. For CNA #6, there was no evidence of any annual abuse or dementia training. OSM #5 stated she had been told about a waiver which relieved the facility staff of any annual training…

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 facility document review, it was determined that the facility staff failed to act upon a reported grievance for a missing personal item for one of 33 residents in the survey sample, Resident #32 (R32). The findings include: The facility staff failed to respond to a known grievance regarding a missing Prevalon boot (boot to keep the heel lifted off the bed, wick moisture and keep the foot and ankle in place) in a timely manner for R32. R32 was admitted to the facility with diagnoses that included but were not limited to paraplegia and chronic ulcer of left calf. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/20/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G documented R32 requiring extensive assistance of two or more persons for transfers, personal hygiene and extensive assistance of one person for dressing. Section G…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to complete a comprehensive assessment with a change in ADL (activity of daily living) status for one of 33 residents in the survey sample, Resident #25 (R25). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/22/2022, the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is moderately cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member physical assistance for moving in the bed, transfers, moving on the unit, dressing, toileting, personal hygiene and bathing. The resident was coded as requiring supervision with one staff member physical assistance for eating. The MDS prior to the 5/22/2022, an annual assessment, with an ARD of 2/10/2022, the resident scored a 10 out of 15 on the BIMS score, indicating…

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, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide an accurate assessment for one of 33 residents, Resident #37. The facility staff failed to complete an accurate MDS (minimum data set); annual assessment for Resident #37. The findings include: Resident #37 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, diabetes mellitus, heart failure and encephalopathy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing, hygiene and bathing; supervision for locomotion and independence for eating.…

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 interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to actively assist one of 33 residents in the survey sample with discharge planning for a resident requested discharge, Resident #32 (R32). The findings include: The facility staff failed to actively participate when requested by R32 to coordinate a discharge from the facility. R32 was admitted to the facility with diagnoses that included but were not limited to paraplegia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/20/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G documented R32 using a wheelchair and having functional limitations in range of motion in both lower extremities. On 7/19/2022 at 12:59 p.m., an interview was conducted with R32. R32 stated that they were paralyzed…

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 staff interview and clinical record review, it was determined the facility staff failed to assess for a decline in functional status for one of 33 residents in the survey sample, Resident #25 (R25). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/22/2022, the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member physical assistance for moving in the bed, transfers, moving on the unit, dressing, toileting, personal hygiene and bathing. The resident was coded as requiring supervision with one staff member physical assistance for eating. The MDS prior to the 5/22/2022, an annual assessment, with an ARD of 2/10/2022, the resident scored a 10 out of 15 on the BIMS score, indicating the resident was moderately cognitively impaired for making daily decisions.…

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 facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents per resident choice for 2 of 33 residents in the survey sample, Resident #32 (R32) and Resident #22 (R22). The findings include: 1. The facility staff failed to provide showers per resident choice/preference to R32. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/20/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G documented R32 requiring extensive assistance of two or more persons for transfers, personal hygiene and extensive assistance of one person for dressing. Section G documented R32 being totally dependent on one person for bathing. On 7/19/2022 at 12:59 p.m., an interview was conducted with R32. R32 stated that they had to ask the staff for showers and that they were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer oxygen per the physician order for one of 33 residents in the survey sample, Resident #94 (R94). The findings include: On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 7/7/2022, the resident was not coded for cognition. In the nurse's notes it was documented the resident refused to answer the questions. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as using oxygen. Observation was made of R94 on 7/19/2022 at approximately 12:00 p.m. R94 was in the bed with the oxygen on via a nasal cannula. The oxygen concentrator was set with the bottom of the black ball sitting on the 1.5 line and the top of the ball on the 2.0 line. A second observation was made on 7/20/2022 at 2:48 p.m. The oxygen was in use via nasal cannula. The oxygen concentrator was set with the top 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 resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide medically related social services to one of 33 residents in the survey sample, Resident #32 (R32). The findings include: The facility staff failed to actively assist R32 in coordinating a resident requested discharge from the facility. R32 was admitted to the facility with diagnoses that included but were not limited to paraplegia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/20/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G documented R32 using a wheelchair and having functional limitations in range of motion in both lower extremities. On 7/19/2022 at 12:59 p.m., an interview was conducted with R32. R32 stated that they were paralyzed and used a manual wheelchair…

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, facility document review, and clinical record review, it was determined that the facility staff failed to serve food at palatable taste and temperature for 3 of 33 residents in the survey sample, Residents #49 (R49), #28 (R28), #41 (R41). The facility staff failed to serve food at a palatable taste and temperature at lunch on 7/19/22. The findings include: 1. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/10/22, R49 was coded as being cognitively intact for making daily decisions, having scored 14 out of 15 on the BIMS (brief interview for mental status). On 7/19/22 at 1:01 p.m., an interview was conducted with R49. The resident stated the facility food was lousy, cold, and not good. 2. On the most recent MDS, an annual assessment with an ARD of 5/12/22, R28 was coded as being cognitively intact for making daily decisions, having scored 13 of 15 on the BIMS. On 7/19/22 at 11:45 a.m., R28 stated the food was not good, both in taste and temperature. 3. On the 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 staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for two of 41 residents in the survey sample, Residents #80 and #55. The facility staff failed to transcribe a physician order for Resident #80's bilateral knee braces accurately to the TAR (treatment administration record). The facility staff failed to clarify multiple as needed pain medication orders for Resident #55 to determine when and which medication to administer based on pain level parameters. The findings include: 1. Resident #80 was admitted to the facility on [DATE]; with a recent readmission on [DATE] with diagnoses that included but were not limited to end stage renal disease requiring hemodialysis [a procedure used in toxic conditions and renal [kidney] failure, in which wastes and impurities are removed from the blood by a special machine.] (1), peripheral vascular disease [any abnormal condition, including atherosclerosis,…

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, it was determined that the facility staff failed to serve food in a sanitary manner. During the lunch meal on 3/3/2020, OSM (other staff member) #4, a dietary aide, was observed plating food for resident trays. OSM #4 touched multiple items while wearing gloves and then wearing the same gloves touched the food contact, surface area of plates, and grabbed dinner rolls with his hand, placing one on each plate, wearing the same gloves. The findings include: On 3/3/20 at 11:46 AM, an inspection of the tray line service was conducted of the lunch meal. The preparation of the meal trays began at 12:27 PM. The following was observed: OSM #4 (Other Staff Member, dietary aide) was at the steam table, plating the food for each tray. He had gloves on, however; he was noted to be touching multiple items in his vicinity including serving spoon handles, the surface of the steam table, and the handles of a wheeled cart on which plates were stacked at his left side, contaminating his gloves. As he obtained each plate from the cart,…

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 and staff interview it was determined that the facility failed to ensure a complete and accurate medical record for one of 41 residents in the survey sample, Resident # 7. The facility staff failed to document the percentage of food eaten by Resident #7 at meals. The findings include: Resident # 7 was admitted to the facility with diagnoses that included but were not limited to swallowing difficulties, amnesia, and adult failure to thrive. Resident # 7's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/27/2020, coded Resident # 7 as scoring a 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition for making daily decisions. Resident # 7 was coded as independent and requiring assistance with setup for eating. Section K Swallowing/Nutritional Status coded Resident # 7 under K0300 Weight Loss, 2 [two] Yes, not on physician-prescribed weight-loss regimen. 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, staff interview, and facility document review, it was determined that the facility staff failed to ensure the kitchen area was free of pests. Two flies were observed flying in the area where dishes were stored on racks for air-drying, and a fly was observed flying around the area of the steam table where the lunch meal foods was already set up but were covered. The findings include: On 3/3/20 at 10:15 AM, an initial kitchen inspection was conducted. Two flies were observed flying in the area where dishes were stored on racks for air-drying, located between the dishwashing area and a storage area across the aisle from the dishwashing area. On 3/3/20 at 12:24 PM, an inspection of the tray line service was conducted of the lunch meal. A fly was observed flying around the area of the steam table where the lunch meal foods was already set up but were covered. A review of the pest control company visits for December 2019, January 2020, and February 2020 revealed a visit dated 2/18/20 which documented, Targeted Pests: Flies, Miscellaneous flies, Other, Fats, Oil,…

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, facility document review and clinical record review, it was determined that facility staff failed to promote resident dignity for two of 41 residents in the survey sample, Residents # 82 and # 43. During the lunch meal service on 3/3/2020 Resident #82 and #43, did not receive their meal for approximately 19 minutes, after staff served the five other residents seated at the same table, and the residents were eating their meals. The findings include: Resident # 82 was admitted to the facility with diagnoses that included but were not limited to: heart failure and swallowing difficulties. Resident # 82's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/14/2020, coded Resident # 82 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 82 was coded as requiring supervision and assistance with setup for eating. Resident # 43…

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, clinical record review, and facility document review, it was determined that the facility staff failed to immediately notify and consult the physician for a change in condition, for one of 41 residents in the survey sample, Resident #93. The facility staff identified an unstageable wound on Resident #93's left heel on 11/19/19, and failed to immediately notify and consult the physician and wound care nurse about the wound and treatment initiated, until 11/22/19. The findings include: A review of the facility policy, Notification of Change in Condition documented, The nurse to notify the attending physician and Resident Representative when there is a(n): *Accident, *Significant change in the patient/resident's physical, mental, or psychosocial status, *Need to alter treatment significantly . Resident #93 was admitted on [DATE]; diagnoses include but are not limited to peripheral vascular disease, stricture of artery, occlusion and stenosis of right and left carotid arteries, stroke, 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the facility abuse policy for reporting an allegation of abuse for one of 41 residents in the survey sample, Resident #89. Resident #89 alleged a CNA (certified nursing assistant) had abused him causing a scratch on the left elbow that was bleeding on 2/21/2020 at 5:30 a.m. The facility staff did not report the allegation to the State Agency until 2/21/20 at 11:21 AM, approximately five hours and fifty-one minutes after the alleged abuse occurred. The findings include: Resident #89 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Parkinson's disease (slowly progressive neurological disorder) (1), congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys (2), dementia (progressive state of mental decline, memory function and judgement) (3). Resident #89's 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to report an allegation of abuse in a timely manner for one of 41 residents in the survey sample, Resident #89. On 2/21/2020 at 5:30 a.m., Resident #89 alleged a CNA (certified nursing assistant) had abused him causing a scratch on the left elbow that was bleeding, and was not reported to the State Agency until 2/21/20 at 11:21 AM, five hours and fifty-one minutes after the alleged abuse occurred. The findings include: Resident #89 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Parkinson's disease (slowly progressive neurological disorder) (1), congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys (2), dementia (progressive state of mental decline, memory function and judgement) (3). Resident #89's most recent MDS (minimum data set) assessment, a quarterly assessment,…

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, clinical record review and facility document review, it was determined the facility staff failed to evidence an accurate PASARR (preadmission screening and resident review) screening for one of 41 residents in the survey sample, Resident #69. The facility failed to ensure an accurate PASARR was completed upon admission for Resident #69. The findings include: Resident #69 was admitted to the facility on [DATE]. Resident #69's diagnoses included but were not limited to: dementia (progressive state of mental decline, memory function and judgement) (1), bipolar disorder (mental disorder characterized by mania and depression) (2), psychosis (mental disorder with detachment from reality and impaired perceptions and thinking) (3). Resident #69's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/6/20, coded the resident as scoring 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was 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 staff interview and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 41 residents in the survey sample, Resident #348. The facility failed to develop a baseline care plan to include and address the care of Resident #348's PICC (peripherally inserted central catheter). The findings include: Resident #348 was admitted to the facility on [DATE]. Resident #348's diagnoses that included but are not limited to: cellulitis (inflammation of tissue) (1), diabetes mellitus (altered glucose metabolism caused by the inability of insulin to function normally in the body) (2) and chronic obstructive pulmonary disease (chronic non-reversible lung disease) (3). Resident #348's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/21/20, coded the resident as scoring 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A 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 clinical record review and staff interview it was determined that the facility failed to ensure a complete and accurate medical record for one of 41 residents in the survey sample, Resident # 7. The facility staff failed to document the percentage of food eaten at meals for Resident #7. The findings include: Resident # 7 was admitted to the facility with diagnoses that included but were not limited to swallowing difficulties, amnesia, and adult failure to thrive. Resident # 7's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/27/2020, coded Resident # 7 as scoring a 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition for making daily decisions. Resident # 7 was coded as independent and requiring assistance with setup for eating. Section K Swallowing/Nutritional Status coded Resident # 7 under K0300 Weight Loss, 2 [two] Yes, not on physician-prescribed weight-loss regimen. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to provide treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for two of 41 residents in the survey sample, (Residents # 4 and Resident #7). The facility staff failed to ensure Resident #4 received only nectar-thickened liquids per the physician orders. On 3/3/2020 during the lunch meal CNA (certified nursing assistant) # 3, was observed providing Resident # 4 two sips thin consistency juice by use of a straw. The facility staff failed to administer Mighty House Shake [liquid dietary supplement] to Resident # 7 according to the physician order. The findings include: 1. Resident # 4 was admitted to the facility with diagnoses that included but were not limited to: aphasia [1] and swallowing difficulties. Resident # 4's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment…

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, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for the prevention and treatment of pressure injuries for two of 41 residents in the survey sample, Residents #80 and #93. For Resident #93 the facility staff failed to provide care and services for the treatment of a pressure wound once identified, for 3 days. On 11/19/19, the facility staff identified an unstageable wound on the left heel. The physician and wound care nurse were not notified of the wound and treatment was not initiated until 11/22/19. The facility staff failed to transcribe a physician order for Resident #80's bilateral knee braces accurately to the TAR (treatment administration record), as a result staff failed to ensure Resident #80's bilateral knee braces were kept open while the resident was in bed to prevent the development of a pressure injury. The findings include: 1. Resident #93 was admitted on [DATE]. Diagnoses include…

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, and facility document review, it was determined that facility staff failed to ensure a PPD [purified protein derivative] [1] vial was dated when opened and an expired PPD vial were not available for use in one of one medication storage rooms inspected, second floor medication room. The findings include: On 03/05/20 at 8:36 a.m., an observation of the facility's medication room on the second floor was conducted with RN [registered nurse] # 3. Upon entering the medication room, a small refrigerator was observed under the counter on the left side of the room. Observation of the inside of the refrigerator revealed a small red plastic tray containing two multi-dose vials of PPD that were available for use. When asked if the vials of PPD were opened, RN # 3 stated yes. Observation of the first vial failed to evidence an open date. The second opened vial of PPD documented an open date of 1/28/2020. When asked about the first vial of PPD not having an open date, RN # 3 observed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to implement infection control practices for one of 41 residents in the survey sample, Residents # 4. During the lunch meal observation on 3/3/2020, CNA (certified nursing assistant) #3 was not observed sanitizing or washing their hands while after assisting a resident with their meal and before they resumed assisting Resident #4 with their meal. The findings include: Resident # 4 was admitted to the facility with diagnoses that included but were not limited to: aphasia [1] and swallowing difficulties. Resident # 4's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/27/2020, coded Resident # 4 as scoring a three on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition for making daily decisions. Resident # 4 was coded as requiring extensive assistance of one 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.