Life Care Center Of Skagit Valley

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 1 of 5 sampled residents (Resident 1) reviewed for PASRR. Failure to obtain the PASRR and PASRR determination letter prior to admission placed the resident at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability. Findings included.Review of a facility policy titled Pre-admission Screening and Resident Review (PASARR) documented the facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure broken window locking devices were repaired and window screens were available and repaired timely for 2 of 3 rooms (rooms [ROOM NUMBERS]) reviewed for safe, functional and comfortable environment for residents, staff and the public. These failures placed residents and the public at risk of potentially avoidable accidents, lack of dignity and diminished quality of life.Findings included . In an interview on 02/19/2026 at 12:50 PM Collateral Contact 1, (CC1) Resident 1's family member stated there was a concern about the window in Resident 1's room, room [ROOM NUMBER]. CC 1 stated Resident 1 moved into the room on 10/30/2025 and the window locking mechanism on the left window panel was broken and there was no window screen. CC1 stated there was nothing in place to secure the window and posed a safety risk as anyone from inside or outside could push the window to the side to enter or exit Resident 1's room. CC1 stated instead of fixing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medically related social services and to advocate for 1 of 2 cognitively impaired residents (Resident 1) reviewed for advanced directives. The facility failed to advocate, educate, and obtain appropriate legal assistance in the development of an advanced directive and placed residents at risk of not having their rights and wishes honored. Findings included. Review of a facility policy titled, Advanced Directives and Advanced Care Planning (ACP) last reviewed 09/26/2025 documented each time a resident was admitted to the facility, quarterly, and when a change in condition was noted in the resident's condition, the facility reviewed the advance directive and advance care planning information. The review focused on if the existing advanced directives and ACP matched the current goals of care for the resident. The social services director or designee documented conversations in the medical record and assisted as needed with updating the documents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 1 of 3 sample residents (Resident 4) whose CP was reviewed for discharge planning and urinary status. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included.Resident 4 was admitted to the facility on [DATE] with diagnoses to include perineal (area between the genitals and the anus) and sacral (area between the bottom of the spine and tailbone) wounds, urinary incontinence, and cognitive impairment. Review of the Quarterly Minimum Data Set (MDS - an assessment tool) assessment, the resident had no cognitive impairment, was continent of their bowel and bladder, and did not have an indwelling urinary catheter. Review of Resident 4's discharge CP, date initiated 04/10/2025 and revised on 04/17/2025, showed the goal was to develop and follow full discharge plan with comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure clinical records were accurate for 2 of 3 residents (Residents 4 and 9) reviewed for wounds. The failure to ensure the residents' clinical records were accurate placed them at risk for unmet care needs, and for having records that did not reflect the actual care provided. Findings included . Review of the facility's Area of Focus: Basic Skin Management policy, revised on 11/21/2024, showed the resident would have:-A head-to-toe skin inspections upon admission/readmission, completed weekly and as needed by the nursing documented on the NRSG: Weekly Skin document in Point Click Care (PCC).-If a new [NAME] alteration/wound was identified, the nurse performed and documented an assessment/observation of the resident's skin.-Wound assessments/observations were required at a minimum of weekly and when there was a change. This was documented utilizing the PCC assessment NRSG WOT.<RESIDENT 4> Resident 4 was admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure resident preferences for food were obtained and honored for 4 of 4 residents (Residents 5, 21, 35, and 45) reviewed for choices. The facility refused to allow residents the ability to safely consume food items that were brought from outside sources when they removed the ability to heat up their food. This resulted in the residents losing their ability to choose their meal of preference and snacks of choice. These failures placed residents at risk for decreased quality of life. Review of the facility policy titled Resident Rights, reviewed 09/10/2024 stated residents had the right to self-determination with access to people and services in and outside of the facility. Residents had the right to make choices about aspects of their life in the facility that are significant to the resident. Review of the facility policy titled Food from Outside Sources, dated 06/03/2024 documented that when there was food that required heating the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure a clean, comfortable, homelike environment in 2 of 4 halls (shared bathroom between room [ROOM NUMBER]-215, and 114-115), in 1 of 3 shower rooms (community shower room for 400/500 halls), and 1 of 1 dining rooms. Failure to ensure the facility was clean, comfortable, and homelike placed residents at risk for decreased quality of life, compromised dignity, and potential infection control issues. Findings included . Review of the facility policy titled Resident Belongings and Home Like Environment, reviewed 05/15/2025 states the facility will provide a clean, safe, comfortable, homelike environment to the residents .homelike environment de-emphasizes the institutional character of the setting to the extent possible and supports a more home like environment .it was the responsibility of the facility staff to create and provide a homelike environment. <RESIDENT BATHROOMS> During an observation of the shared bathroom between rooms [ROOM NUMBERS] 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, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs - daily hygiene and other self-care tasks) for 4 of 7 residents (Residents 6, 7, 17, and 8) reviewed for ADLs. The failure to provide ADL assistance to residents placed residents at risk for poor hygiene, diminished feelings of self-worth, and other adverse health outcomes. Findings included . Review of a facility policy titled Activities of Daily Living (ADLs) review date of 09/01/2024, documented 'The resident will receive assistance as needed to complete activities of daily living (ADLs).' <RESIDENT 7> Resident 7 was a long-term resident at the facility. According to the Annual Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident was cognitively intact and was dependent (helper does all the effort) on staff for shower assistance. During observations on 06/13/2025 at 12:33 PM, 06/16/2025 at 8:33 AM, and 06/17/2025 at 8:36 AM, Resident 7's hair appeared…

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

Based on observation, interview and record review, the facility failed to provide meals that were palatable and at an appetizing temperature per 1 of 1 resident groups (Residents 3, 19, 35, 46, 59, and 182), 3 resident interviews (Residents 19, 37, and 45), and 2 of 3 resident dietary grievances (Residents 46, and 50) reviewed. These failures resulted in residents experiencing dissatisfaction with their meals and placed residents at risk for decreased quality of life and weight loss. Findings included . In an interview on 06/12/2025 at 2:15 PM, Resident 45 stated they did not think the fish was fresh and stated the facility uses the wrong seasonings, and the meats are too tough. Resident 45 stated they took the microwave away and we can't have popcorn anymore. In an interview on 06/12/2025 at 2:20 PM, Resident 19 stated food options were limited, lots of chicken fried or country fried, not a lot of variety. In an interview on 06/12/2025 at 10:06 AM, Resident 37 stated the food tasted bad, they offer other options, but the options are also not good. In an observation of the facility…

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

Based on interview and record review, the facility failed to ensure their policy for foods brought in from outside sources was implemented. The facility failed to ensure safe and sanitary storage, handling and consumption of the foods brought into the facility. This failure placed residents at risk for decreased quality of life related to an inability to exercise their rights and preferences to have food items of their choice brought into the facility and safely stored and consumed. Findings included . Review of the facility policy titled, Food from Outside Sources, 06/03/2024 stated that when food required to be heated the facility should use a food thermometer and alcohol wipes to ensure food was heated properly .additionally facility staff should receive proper education on required food temperatures, and proper use of food thermometer. In a review of an undated letter from Staff A, Administrator addressed to residents, staff and family members. The letter included an attachment, that stated they were only allowed to store a small number of items for the residents and would no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to conduct a thorough investigation of an injury of unknown source for 1 of 6 residents (Resident 30) to rule out abuse and neglect. This failed practice placed residents at risk for potential unrecognized abuse or neglect. Findings included . Review of the Facility Policy titled Abuse: Investigations review date 06/17/2024, stated the facility would investigate incidents of unknown source thoroughly to allow the Administrator to determine what actions are necessary (if any) for the protection of residents. Investigations would include, but were not limited to: - Conducting observations of the alleged victim including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents, and interactions/relationships between resident to other residents; - Conducting interviews with, as appropriate, the alleged victim 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 interview and record review the facility failed to ensure timely completion and transmission of required Minimum Data Set Assessments (MDS) (a required assessment tool) for 1 of 3 residents (Resident 62) reviewed for discharge process. Failure to complete the required discharge assessment as required can impact the accuracy of the facility's quality measures and has the potential to affect facility payments. Findings included . The code of federal regulations (CFR) 42 requires skilled nursing facilities to provide a discharge assessment that accurately reflects a resident's status at discharge within 14 days of the resident's date of discharge and to encode/transmit that data to the Centers for Medicare and Medicaid Services (CMS) within 14 days. Resident 62 was admitted to the facility on [DATE] and discharged on 01/24/2025. Review of Resident 62's clinical record on 06/13/2025 showed there was no discharge MDS completed for Resident 62. The CMS system had flagged the resident file as being without 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were provided with interventions to maintain or prevent declines in range of motion (ROM) for 1 of 3 residents (Resident 27) reviewed for positioning and mobility. Failure to apply splints and braces as ordered can result in increased contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), decreased mobility, and/or increased pain and diminished quality of life. Findings included . Resident 27 was admitted to the facility on [DATE] with admitting diagnoses to include stroke with hemiplegia (muscle weakness on one side of the body) and hemiparesis (weakness or inability to move one side of the body). According to the Quarterly Minimum Date Set (MDS - an assessment tool) assessment dated [DATE] resident was cognitively intact, receiving restorative nursing program and was wearing splints. Review of Resident 27's physician orders with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents' menus and individual food plans met the nutritional needs and preferences for 1 of 2 residents (Resident 7) reviewed for food preferences. The failure to ensure residents received foods that met their nutritional needs, and their individual preferences placed residents at risk for weight loss, dissatisfaction with their food and diminished quality of life Finding included . Review of facility policy titled Food Allergies and Intolerances review date 04/29/2025 documented that each resident receives and the facility provides food that accommodates resident allergies, intolerances and preferences. The Director of food and Nutrition identifies menu items that contain the food item(s) related to allergy/intolerances and ensures those items are not used in foods prepared and served to identified residents. <Resident 7> Resident 7 was a long-term resident at the facility with a diagnosis that included malnutrition, dysphasia…

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 and interview, the facility failed to ensure foods were prepared under sanitary conditions for 1 of 1 facility kitchens, and to ensure expired items were discarded from 1 of 2 nourishment refrigerators. These failures places resident at risk for food borne illness. Findings included . In an observation of nourishment refrigerators on 06/17/2025 at 11:28 AM, the nourishment refrigerator in the main dining room was observed to include an opened carton of thick and easy supplement which was dated as opened on 06/15/2025. Further observation of the carton showed a manufacturer printed expiration date of 06/13/2025. In observations of meal preparation and tray line on 06/16/2025 between 11:17AM and 12:48 PM the following was observed: - At 11:44 AM, Staff H, Cook, was observed to reach under a table for an item that had dropped on the floor, which was observed to be a meal ticket. Staff H disposed of the ticket in a nearby trash can, doffed (removed) gloves, and donned (put on) a new pair of gloves without performing hand hygiene. - At 12:06 PM, Staff H changed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 1 residents (Resident 30) reviewed for Transmission Based Precaution (TBP-are a set of infection control measures used in healthcare settings to prevent the spread of infectious diseases that are transmitted through contact with an infected patient, their bodily fluids, or contaminated surfaces or objects), 1 of 2 residents (Resident 13) reviewed for Enhanced Barrier Precaution (EBP-infection control intervention designed to reduce transmissions of multi-drug resistant organisms (MDROs in nursing homes) and 1 of 3 residents (Resident 27) observed during personal care. These failures placed residents and staff at risk for potential infection from cross contamination of infectious organisms. Findings included . According to the facility policy titled Enhanced Barrier Precautions with a revised date of 04/22/2025, stated EBP were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility administration failed to obtain and use resources to manage the facility effectively and efficiently to maintain substantial compliance with federal and state regulatory requirements and to meet the significant health needs of their residents. The administration failed to provide needed administrative oversight and monitoring of facility personnel, systems, and policies and practices related to care planning, the resident environment, provision of activities of daily living for dependent residents, range of motion services, respiratory cares, sufficient nursing staff, provision of medically related social services, pharmacy services and procedures, food service procedures, infection control and prevention, and in tuberculosis two-step skin testing. This failed practice placed all residents at risk for unmet care needs and diminished quality of life. Findings included . Review of the facility's last annual recertification Statement of Deficiencies…

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

Based on interview and record review, the facility failed to initiate a grievance from 1 of 1 resident groups (Resident Council) reviewed for grievances. The facility's failure to initiate, log, investigate verbalized concerns, and inform the resident of their findings and the actions taken, precluded the facility from identifying grievance trends and placed the residents at risk of feeling frustrated, unimportant, and with a decreased self-worth and quality of life. Findings included . <Facility Policy> Review of the facility policy titled Grievance Program (Concern and Comment) revised 09/15/2022 showed the program was utilized to address concerns of the residents, family members and visitors. The procedure included any staff member could help in the completion of the Concern and Comment form if a concern or comment was expressed. The administrator was responsible for collaborating with the interdisciplinary team to identify and address repeated concerns from residents and families. In the Resident Council Meeting on 09/10/2024 at 12:15 PM, three out of seven residents voiced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to develop and implement a comprehensive person-centered care plan for six of 18 sampled residents (Residents 5, 6, 8, 49, 53 and 168) reviewed for care planning. This failure placed residents at risk for unidentified outcomes or goals, inconsistent or lack of interventions, and diminished quality of life. Findings included . Review of the facility policy titled: Comprehensive Care Plan and Revisions (dated 03/22/2022) showed the comprehensive care plan would be developed within seven days of the comprehensive assessment. <RESIDENT 6> Resident 6 admitted [DATE] with diagnoses which included a stroke with left sided weakness, diabetes and a history of bilateral (both sides) below the knee amputations. The admission Minimum Data Set (MDS - an assessment tool) assessment, dated 04/11/2024 showed the resident had limb prosthesis marked yes. Review of the resident's current care plan on 09/10/2024 showed the resident's history of amputations and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Care Plans (CPs) were accurately reviewed and revised to reflect current resident status and needs for 4 of 18 sample residents (Residents 2, 6, 43, 53) reviewed for care planning. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled: Comprehensive Care Plan and Revisions (dated 03/22/2022) showed the comprehensive care plan would be developed within seven days of the comprehensive assessment and reviewed and revised after each assessment, including comprehensive and quarterly assessments and the facility would monitor the resident to idenify changes that would warrant updates to the care plan. <RESIDENT 6> Resident 6 admitted [DATE] with diagnoses which included a stroke with left sided weakness, diabetes and a history of bilateral (both sides) below the knee amputations. Review of Resident 6's medical record on 09/11/2024 showed they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 5 of 8 sampled dependent residents (7, 8, 23, 24, and 28) reviewed for ADL's. The facility failed to provide showers/bathing assistance to residents (7, 8, 23, and 28), who were dependent on staff for bathing, and failed to ensure Resident 24 who was dependent for assistance with toileting was provided the necessary assistance. These failures placed the residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living (ADLs), reviewed 09/10/2024 states all residents will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform will be reported to the nurse. <TOILETING CARE> Resident 24 admitted to the facility on [DATE] with diagnoses that included fracture of the right femur, chronic heart failure,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 6 (8, 13,17,20, 42 and 51) resident interviews; Resident Council (3, 9, 20, 36) and as evidenced by failed practice in many identified quality of life and quality of care areas. The facility had insufficient staff to ensure residents received assistance with activities of daily living (ADL) including grooming and showers, assessments, care planning, care plan revision, respiratory care, restorative services, pain management, medication administration and call light response in accordance with established clinical standards, and resident needs and preferences. These failures placed residents at risk for unmet care needs and negative outcomes. Findings Included . Review of the Facility Assessment on 07/24/2024, showed: -Nurse staffing was that it was sufficient to meet resident needs. -CNA staffing was somewhat variable as there have been isolated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely administration of scheduled medications for 4 of 4 sample residents (Residents 16, 1, 38, 7) reviewed who had not yet received their morning medications though the facility's AM Medication Pass times had elapsed. This failure resulted in residents not receiving timely pain medications, anticoagulant medications, medication ordered to be given with breakfast not given until hours after breakfast, diabetic medication, and medication for breathing problems. This failed practice resulted in Resident 16 reporting 10/10 pain two consecutive mornings in a row and it placed residents at risk for adverse medication-related outcomes and for diminished quality of life. Findings included . Review of the undated facility medication administration times schedule showed the AM Med Pass was scheduled for 6:00 AM - 10:00 AM. <RESIDENT 16> Resident 16 admitted to the facility on [DATE] with diagnoses to include chronic pain syndrome. According…

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

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens. The failure to ensure staff wore hair restraints placed residents at risk for receiving food contaminated by hairs from staff not utilizing hair restraints. Findings included . Review of the facility policy titled Associate Conduct and Dress Code, revised date 04/30/2024, showed Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. In an observation on 09/09/2024 at 5:55 AM, Staff C, Dietary Manager, was working in the kitchen without their hair restrained. In an observation on 09/10/2024 at 1:28 PM, Staff D, Dietary Aide, was observed working in the kitchen without their hair restrained. In an interview on 09/10/2024 at 1:50 PM, Staff C was asked about Staff D not wearing a hair restraint while working in the kitchen, they stated Staff D had just started two days ago and they were still working on training them. In an observation on 09/11/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standard of practice for 1 of 4 meal carts (Cart 2) during dining service, 1 of 1 staff (Staff P) during peri-care (cleaning the genital and anal areas of a resident), and 1 of 3 resident rooms (room [ROOM NUMBER]) for transmission-based precautions (TBP). The facility failed to ensure the staff were compliant with appropriate hand hygiene practices while serving meals, and while they assisted a resident with toileting needs. The facility failed to ensure the appropriate type of TBP was initiated for a resident on contact enteric isolation precautions for Clostridium difficile [(c. diff) spore-producing pathogen that can cause diarrhea and inflammation of the colon]. These failures place all residents and staff at risk for potential infections. Findings include . Review of the facility policy titled, Hand Hygiene, revised on 06/03/2024 stated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and/or maintain Advance Directives (AD) for 1 of 2 sampled residents (Resident 24) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 24 admitted to the facility on [DATE] with diagnoses that included fracture of the right femur, chronic heart failure, and kidney disease. Review of Resident 24's care plan dated 07/22/2024 documented they had a Power of Attorney (POA) for healthcare and their daughter was specified as their POA. Review of Resident 24's electronic medical record showed no POA paperwork. In an interview on 09/11/2024 at 12:45 PM Staff W, Licensed Practical Nurse, stated a resident's POA should be documented on the face sheet and located in the chart. Staff W stated Resident 24's daughter was their POA. Staff W checked the electronic medical record and was not able to locate POA documentation for the resident. In 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 and interview, the facility failed to ensure a homelike environment for 3 of 3 sample residents' (11, 28, 17) rooms reviewed for a homelike environment and for unclean windows and screens in the facility conference room. The failure to provide homelike décor/furnishings and to ensure clean room windows and screens placed the residents at risk for living in an institutionalized environment and for having to look through soiled windows and screens. This failed practice also placed staff and the public at risk for having to look out soiled windows and screens in the facility conference room. Findings included . <RESIDENT 11> Resident 11 admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS) assessment, dated 07/05/2024, the resident had severe cognitive impairment. In an observation on 09/09/2024 at 12:11 PM, Resident 11's room had no personal belongings or décor at all, there were no pictures, and the walls were bare. In an interview and observation on 09/10/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify a Significant Change in Status for 1 of 2 sampled residents (Resident 43), reviewed for Hospice services. Failure to identify and complete a Significant Change in Status assessment, according to the Resident Assessment Instrument (RAI) requirements, placed residents at risk for inadequate care planning and a diminished quality of life. Findings included . Record review of the Long-Term Care Facility Resident Assessment Instrument, User's Manual, Version 3.0, dated October 2019, showed that a Significant Change in Status Assessment (SCSA) (A comprehensive assessment), must be conducted within two weeks of the resident's election of their Hospice benefit. Review of Resident 43's medical record showed they admitted on [DATE] and were not receiving Hospice services. The record showed the resident elected their Hospice benefit on 08/10/2024. The RAI manual required the facility to conduct a SCSA within 14 days (by 08/24/2024). 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 interview and record review, the facility failed to complete a discharge summary, including a recapitulation of the resident's stay as required, for 1 of 3 sampled residents ( Resident 65), reviewed for discharge. These failures placed residents at risk of post-discharge complications, delayed treatment, and decline in their overall condition by not having the necessary information and services established to ensure continuity of care for a successful discharge to the community. Findings included . Review of the facility policy titled Discharge Summary dated 05/06/2019 showed the social service and nursing staff participate in developing the discharge summary. The discharge summary included a recapitulation of the resident's stay, a final summary of the resident's status to include cognitive patterns, customary routine, psychological well-being Resident 67 admitted to the facility on [DATE] with diagnoses that included neutropenia (low count of a type of white blood cell), pulmonary fibrosis (scarring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 3 of 4 residents (5, 17, and 23) reviewed for limited Range of Motion (ROM) received necessary care and services to maintain level of functioning and/or prevent decline. The facility failed to ensure residents was evaluated and were provided the appropriate care and services, they failed to ensure consistent use of braces/splints were implemented as ordered and failed to ensure residents received appropriate restorative nursing services programs as ordered. This failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life. Finding included . Review of the facility policy titled, Restorative Nursing, revised 08/20/2024 states a restorative program may be developed by proactively identifying, care planning and monitoring of resident assessments and indicators. The facility will assess the residents' needs, develop a specific program, provide the care 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 interview and record review, the facility failed to develop and implement nutritional interventions, and evaluate the effectiveness of the interventions for 1 of 5 residents (Resident 23) reviewed for nutritional needs. The facility failed to consistently obtain weights and re-weights, notify appropriate parties, and implement Registered Dietician's (RD) recommendations. This failure placed the residents at risk for delayed identification of weight loss and failed to implement appropriate interventions to prevent continued weight loss and decreased quality of life. Findings include . Review of the facility policy titled, Residents at Risk (RAR), revised 04/30/2024, states the facility conducts weekly resident at risk meetings to review residents identified with problems or concerns related to their nutritional status .the facility will establish a consistent method for weighing residents, monitoring weights over time to identify weight loss, determining interventions and reassessing as appropriate .all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral tube feeding (a medical device used to provide nutrients through a tube directly into the stomach) were followed for 1 of 1 resident (Resident 8), reviewed for tube feeding management. The failure to label/date and discard tube feeding supplies, and syringes placed the resident at risk for infection and related complications. Findings included . Resident 8 admitted to the facility 09/29/2023 with diagnoses including history of a stroke with right side weakness, dysphagia, and malnutrition. The quarterly Minimum Data Set (MDS, an assessment tool) assessment dated [DATE] showed the resident had intact cognition, no refusal of care, had a percutaneous endoscopic gastrostomy (PEG) tube for nutrition that delivered more than 51% of the residents' calories, and more that 501milliliters (ml) of fluid for their overall intake. Review of Resident 8's admission paperwork and hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 2 of 3 residents (Residents 17 and 24) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure the concentrator was set to the ordered dosage for Resident 24's Continuous Positive Airway Pressure (CPAP) (a machine that delivers pressurized air through a mask to the airway allowing a resident to breathe easily and regularly when asleep) and daily oxygen therapy through a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) while awake and failed to ensure an order was in place for the use of oxygen for Resident 17. These failures placed residents at risk for health complications, receiving care and services that were not physician ordered, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration (Safety, Storage, Maintenance) showed 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, interview and record review, the facility failed to provide necessary pain management for 1 of 4 sampled residents (Resident 16) reviewed for pain management. This failure placed residents at risk for avoidable pain and a diminished quality of life. Findings included . <RESIDENT 16> Resident 16 admitted to the facility on [DATE] with diagnoses to include chronic pain syndrome. According to the admission Minimum Data Set assessment (MDS- an assessment tool), dated 08/12/2024, the resident had no cognitive impairment, and they had frequent pain that frequently affected their sleep. The pain care area assessment indicated they had chronic pain and were dependent on opiate medication use for pain relief. In an interview on 09/09/2024 at 9:21 AM, Resident 16 stated they had chronic pain in their back and neck and their pain was usually 8 out of 10, and they also had pain in their left shoulder. In an observation/interview on 09/12/2024 at 11:18 AM, Resident 16 had a grimace on their face, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to advocate and assist 1 of 1 sampled resident (Resident 13) in advocating for their rights within the facility. The failure to assist the resident in having care planning meetings to ensure their voice was heard regarding their care and preferences placed residents at risk for unmet care needs and diminished quality of life. Findings included . <RESIDENT 13> Resident 13 admitted to the facility on [DATE] and they had diagnoses to include Parkinson's disease (a disorder of the central nervous system that affects movement). According to the quarterly Minimum Data Set assessment (an assessment tool), they had moderate cognitive impairment. In an interview on 09/09/2024 at 11:29 AM, Resident 13 stated they were not being bathed according to their preferences as they were only able to bathe once a week, but they wanted to bathe twice a week. In an observation on 09/10/2024 at 12:15 PM, Resident 13 was observed sitting in their wheelchair that had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the infection prevention and control Antibiotic Stewardship Program (ASP, a system-wide implementation of measures for monitoring/tracking of antibiotics along with reducing the risk of unnecessary antibiotic use) was implemented for 1 of 1 resident (Resident 8). This failure increased the resident's risk for development of multidrug-resistant organisms (a bacteria that are resistant to many antibiotics) along with the potential for unidentified nursing care trends that identify risk related to infection prevention. This failure had the potential for adverse outcomes associated with unnecessary or inappropriate antibiotic use and a decrease in quality of life for all facility residents. Findings included . Review of the facility document titled, Statement of Leadership Commitment for Antibiotic Stewardship in a Skilled Nursing Facility, signed by the Medical Director, Director of Nursing Services, Executive Director, Infection Preventionist, 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 interview and record review the facility failed to provide resident focused care through consistent monitoring, assessment and evaluation of the residents' condition and develop interventions for urinary tract infections (UTI) for 1 of 5 sampled residents (Resident 1), reviewed for quality of care. This failure placed residents at risk of medical complications, unmet care needs, and diminished quality of life. Findings included . Review of McGreer's criteria (set of surveillance definitions used to identify infections in long-term care settings) showed the constitutional criteria for a UTI (a set of signs and symptoms that indicate a patient may have an infection, even if diagnostic testing has not confirmed it) included fever, acute change in mental and/or functional status and leukocytosis (high white blood cell count). Resident 1 readmitted to the facility on [DATE] with diagnoses that included recurrent UTI, type two diabetes mellitus (chronic disease with high levels of sugar in the blood), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pharmacy services were provided to meet the needs of 3 of 4 residents (Resident 1,2, and 3) reviewed for medications. The failure to ensure medications were acquired and administered as ordered on the day of admission and follow facility processes for medications not available placed residents at risk for adverse events related to missed medications. Findings included . <Resident 1> Resident 1 was admitted to the facility on [DATE] with diagnoses to include Bipolar Disorder (a mood disorder), Seizure Disorder, Tremors (related to medication side effects), and Thyroid disorder. Review of the admission progress note dated 06/26/2026, showed Resident 1 arrived at the facility at 12:15 PM on 06/26/2024. The resident returned to the hospital on [DATE] and had not returned to the facility. Review of Resident 1's admission orders and Medication Administration Records (MAR) for June 2024 showed: - An order for Quetiapine Fumarate (treats…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 3 of 4 residents (Resident 1, 2, and 3) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility failed to maintain resident's fingernails in satisfactory condition to prevent injury, hygiene, discomfort, and respect for the resident's preferences. Failure to provide adequate care for resident's fingernails placed all residents at risk of injury, discomfort, discomfort, and frustration. Findings included . Review of facility's policy titled, Nail Care, revised on 08/23/2023, showed fingernails were to be kept clean and trimmed to avoid injury or infection. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include depression, anxiety, and contractures. Review of Annual Minimum Data Set (MDS - an assessment tool) assessment, dated 01/24/2024 showed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to thoroughly assess and stage a pressure ulcer at onset and weekly, maintain clear and accurate wound documentation, and develop an individualized care plan for pressure ulcer for 1 of 3 sampled residents (Resident 1) reviewed for pressure ulcers (PU's). This failure placed residents at risk for deterioration of their wounds and for diminished quality of life. Findings included . Review of the Minimum Data Set (MDS, an assessment tool) 3.0 Resident Assessment Instrument manual, v1.19.1, dated October 2019, showed a PU/Pressure injury (PI) defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, because of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. Review of the National Pressure Ulcer Advisory Panel staging, showed a deep tissue pressure injury (DTI) is defined as intact or non-intact skin with localized area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to implement a comprehensive person-centered care plan for 1 of 3 sampled residents (Resident 1) reviewed for implementation of care plans. The facility failed to ensure staff implemented supervised transfer and toileting resident interventions placed residents at risk of feeling of frustration, falls, and potential injury. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) of left side resulting from a stroke. Review of Resident 1's Annual Minimum Data Set (an assessment tool) assessment, dated 07/05/2023, showed the resident was cognitively intact. Resident 1 required two-person extensive assist with transfers, bed mobility, dressing, toilet use, and personal hygiene. Review of current Kardex (care plan for Nursing Assistants (NA)), showed Cares in pairs. Do not leave resident unattended…

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.