Glenhaven

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services for 1 of 2 residents (R2) reviewed for catheters.Findings include:Facility policy titled Indwelling catheter insertion and care, last revised 04/07/25, stated in part,-5. t. Secure the catheter to the client's thigh using the securement device.u. Secure the urine collection bag lower than the client's position.-6. f. Maintain unobstructed urine flow by: i. Keeping the catheter and collection tubing free from kinking.ii. Always keep collection bag below the level of the bladder.R2 was admitted to the facility on [DATE] with diagnoses including in part, urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of bladder, gastro esophageal reflux disease without esophagitis, and insomnia. R2's Minimum Data Set (MDS) assessment, dated 10/29/25, identified R2 required…

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 did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This occurred for 1 of 3 medication carts/storage rooms observed. During the recertification survey, 1 of 3 observations were made of R15's liquid Morphine bottle open with no open date label in medication cart on unit E. Surveyor observed controlled medication Lorazepam not double locked on unit E.Findings include:Facility policy titled Controlled Substance Medication Storage, last revised 05/2018, stated in part,B. Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed double locked compartment sperate from all other medications or per state regulation .Example 1On 03/04/26 at 9:10 AM, Surveyor observed medication cart on unit E with Registered Nurse (RN) R. Surveyor observed a bottle of morphine sulfate oral concentration 100mg/5ml, give 0.25ml by mouth every 2 hours as needed, opened with no open date label. The morphine was dispensed on 12/26/25…

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 did not ensure possibility of abuse was thoroughly investigated for 1 of 3 residents (R), R1 reviewed.R1 obtained multiple bruises of unknown origin; the facility did not complete a thorough investigation of the incident.Federal regulation states, 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: S483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.R1 was admitted on [DATE] with diagnoses that include dementia with anxiety and behaviors, atrial fibrillation, obesity, fibromyalgia, insomnia, and low back pain. R1's minimum data set (MDS), dated [DATE], notes R1 has severe cognitive impairment, is independent with bed mobility and ambulation using a wheeled walker. R1 requires supervision or touching assistance with transfers, toileting, and eating. Surveyor spoke with R1 who could not articulate well enough to communicate effectively.On 08/25/25, Surveyor reviewed 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 observations, interview and record review, the facility did not ensure the resident environment remains free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed. (R1)R1 had multiple bruises to arms and legs. The facility did not find root cause of the arm bruises or put interventions in place to prevent reoccurrence and did not educate staff on ways to prevent injury or recurring bruises.Federal regulation states facilities must ensure that resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents.R1 was admitted on [DATE] with diagnoses that include dementia with anxiety and behaviors, atrial fibrillation, obesity, fibromyalgia, insomnia, and low back pain. R1's minimum data set (MDS), dated [DATE], notes R1 has severe cognitive impairment, is independent with bed mobility and ambulation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure that an alleged violation involving abuse by a Resident (R1) was reported immediately to the Nursing Home Administrator (NHA) and to the State Survey and Certification Agency. An incident involving R1 and R2 occurred on 02/27/25. R1 hit R2 with a closed fist. The facility did not report the abuse to the State Survey and Certification Agency. Findings Include: Facility policy titled, Abuse Policy, shows a most recent review date of 10/04/16, stated, Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's, chronic kidney disease, dementia, difficulty in walking, unsteadiness on feet, and cognitive communication deficit. R1's most recent [NAME] Data Set (MDS) assessment dated [DATE] indicated…

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 did not ensure, in response to resident-to-resident physical abuse, a thorough investigation was conducted to prevent further potential abuse for 1 of 2 (R1) residents reviewed for abuse. The facility did not conduct a thorough investigation of the resident-to-resident-altercation that occurred to R2 on 02/27/25. The facility did not conduct other resident interviews for potential abuse. Findings include: Facility policy titled, Abuse Policy, shows a most recent review date of 10/04/16, stated, Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identity and immediate clinical interventions necessary. R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's, chronic kidney disease, dementia, difficulty in walking, unsteadiness on feet, and cognitive communication deficit. R1's most recent [NAME] Data Set (MDS) assessment dated [DATE] indicated that R1 was able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the resident environment remained as free of accidents hazards as possible. The facility did not update resident's care plan after each event of a fall. This has the potential to affect 1 of 3 residents (R) (R1) reviewed for accidents. Facility did not update R1's care plan after R1's fall risk score increased from 12 to 16 on 02/16/25, and did not update care plan following a bruise noted on 03/05/25 from a fall. Findings include: The facility policy titled, Falls reviewed October 2023, states, 2. When notified a fall has occurred, the licensed nurse will: . R. fill out a care plan update sheet with new interventions for the MDS coordinator S. Make sure intervention and fall are reported through the 24 hr report sheet. t. [Director of Nursing] DON or designee will bring incident report to morning meeting where management team will review to make sure intervention is new, appropriate, documented and accessible to all staff. R1 was admitted to the…

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

Based on observation, interview and policy review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. When staff heated up Resident (R) 124's food in the microwave, staff did not check to ensure the food was at safe eating temperatures. In the kitchen refrigerator there was food that was not dated appropriately to ensure food safety. This has the potential the affect all 19 of 19 residents (R) residing in the facility. Findings include: Example 1 Facility Policy titled, Food temperatures, states, 6. To take hot food temperature, insert the thermometer at 45 degree angle to the middle of the food items taking care not to touch the container or bone if it has one. Wait for the thermometer to rise to the maximum temperature, read and record the temperature and then remove the thermometer from the food item and immediately clen with a fresh alcohol swab. Repeat this process until all hot food temperatures have been taken . 15. Leftovers must be, labeled, covered, cooled and stored (within 1/2 hour after…

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 did not ensure the mandatory staffing data that had been submitted from 01/01/24-09/30/24 was complete, accurate, and auditable. The submitted data from 01/01/24-09/30/24 was not complete, accurate, or auditable. This has the ability to affect all 19 of 19 residents in the facility. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered No RN Hours for the dates of 01/08/24 (MO), 02/02/24 (FR), 03/15/24 (FR), 03/29/24 (FR). The PBJ Staffing Data Reports that were generated quarterly document that the facility triggered Failed to have Licensed Nursing Coverage 24 Hours/Day for the dates of 05/13/24 (MO), 05/16/24 (TH), 05/17/24 (FR), 06/02/24 (SU), 06/03/24 (MO), 06/09/24 (SU), 06/30/24 (SU), 07/06/24 (SA), 08/03/24 (SA), 09/06/24 (FR), 09/29/24 (SU). Surveyor completed record review of daily postings for infraction dates, including nursing schedules, Director of Nursing pay stubs, and Multiple Data Set (MDS) Coordinator pay stubs. Surveyor did…

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 did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 19 residents in the facility. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to affect 19 of 19 residents reviewed. -The facility did not have a complete tracking program in place for the early detection of infections and potentially exposed residents (R). -Observations were made of the facility not implementing Transmission Based Precautions (TBP) for 1 of 1 sampled resident on TBP. -Facility did not have a clear process for handling infectious linens. This is evidenced by: Example 1 The facility policy titled, Water…

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 did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs for residents on blood thinners and bleeding risk. This occurred for 1 of 2 residents (R) reviewed (R3). Findings include: R3 was admitted on [DATE]. R3's diagnoses include unspecified dementia, chronic atrial fibrillation, and essential hypertension. R3's Minimum Data Set (MDS) assessment, completed on 10/22/24, confirmed R3 is currently using an anticoagulant daily for the last 7 days. R3's care plan was reviewed and did not have an anticoagulant/ bleeding risk care plan in place. R3's physician orders indicated: -Warfarin oral tablet 5mg, give 1 tab one time a day every Tuesday, Wednesday, Thursday, Saturday, and Sunday for atrial fibrillation. -Warfarin oral tablet 7.5mg, give 1 tablet by mouth one time a day Monday, and Friday for atrial fibrillation. On 12/09/24 at 12:23 PM, Surveyor interviewed R3's Power of Attorney (POA) I and asked about R3'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 observation, interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury (PI) for one of three residents (R) reviewed for pressure injuries (R2) R2 was admitted to the facility on [DATE], with no skin impairments and developed a stage 2 pressure injury to the coccyx area (tailbone), which remains unhealed, has lack of timely care plan interventions, and lack of repositioning. Findings include: According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is…

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 did not ensure resident safety through assessment and ensure the environment remains as free of accident hazards as is possible for 3 of 4 residents (R) reviewed (R12, R16, and R15). -R12 was evaluated by the facility to be a fall risk with assist of 1 during ambulation. R12 was observed self-ambulating to R12's room from dining room. -R16 was evaluated by the facility to be a fall risk with assist of 1 during ambulation. R16 was observed self-ambulating to R16's room from dining room. -R15 was evaluated by the facility for choking hazard during mealtimes. R15 was observed eating meals alone without supervision. Findings include: R12 was admitted on [DATE]. R12's diagnoses include Parkinson's, history of falling, schizoaffective disorder, polyneuropathy, unsteadiness on feet, reduced mobility, and lack of coordination. R12's MDS assessment, completed on 11/05/24, confirmed R12 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter. R2's Foley catheter was changed on a routine monthly basis without clinical indications and not following professional standards of practice. This occurred for 1 of 2 residents reviewed for urinary catheters. (R2). Findings include: The Centers for Disease Control and Prevention (CDC) suggests changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Record review identified R2 was admitted to the facility on [DATE], with the following diagnoses, in part: benign prostatic hyperplasia with lower urinary tract symptoms, hemiplegia and hemiparesis…

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 did not provide medically related social services to address Post Traumatic Stress Disorder (PTSD) for 1 of 19 residents (R) reviewed to ensure appropriate social services are provided for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being (R17). -The facility failed to provide medically related social service for developing a plan of care addressing R17's PTSD. -The facility failed to provide non-pharmacological interventions for R17 to cope with PTSD and anxiety. This is evidenced by: Findings include: R17 was admitted to the facility on [DATE] with diagnosis which include post-traumatic stress disorder (PTSD), generalized anxiety disorder, major depressive disorder, sleep disturbance, psychophysiological insomnia, and agoraphobia disorder. R17's Minimum Data Set (MDS) assessment, dated 11/26/24, indicated that R17 has a Brief Interview for Medical Status (BIMS) score of 15 out of 15, which…

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 did not ensure that a communication process was implemented, including how the communication will be documented between the long term care (LTC) facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. The facility did not have a communication binder for hospice services to relay information to the facility regarding hospice services. This has the potential to effect 1 of 1 resident (R) investigated for hospice services (R2). Findings include: Surveyor completed record review of R2's progress notes and could not find the communication with hospice besides notes documented by facility staff members. On 12/11/24 at 2:15 PM, Surveyor requested communication for R2 regarding hospice communication and the orders for wound care. The Assistant Director of Nursing (ADON) C admitted they could not locate a communication binder with hospice for R2. Surveyor asked if they had a different system and ADON C said the hospice binder was their main way to communicate with hospice. Hospice…

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 did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 19 residents residing in the facility. Findings include: On 11/28/23 at 10:10 AM, Surveyor interviewed Dietary Director (DD) C regarding their qualifications. DD C said they had started the classes at a previous facility but had not had the opportunity to complete them. At the time of the survey, they were in the process of working on finding a preceptor for DD C so they could continue the classes. When asked if DD C had any other qualifications that would satisfy the regulation, they said they did not. On 11/30/23 at 11:00 AM, record review revealed that DD C was hired on 08/01/23 about four months prior to the survey. Surveyor noted there was no monitoring or supervision of the kitchen operations by the dietician. On 11/30/23 at 11:47 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding expectations for the Dietary…

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 did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety; uncovered food, handling dirty potholder, low holding food temperatures. This has the potential to affect all residents (R) in the facility; 19 of 19 residents could be affected. Findings include: On 12/28/23 at 11:40 AM, Surveyor observed Dietary Aide (DA) F drop a potholder used for holding hot items. DA F was loading hot food for the skilled nursing facility when they dropped the potholder on the floor. DA F picked up the potholder off the floor and continued to use the same potholder to load the rest of the hot food. The hot food packed was pureed, mechanical, and normal diet-type foods. The dirty potholder had contact with the food trays being loaded. On 12/28/23 at 11:55 AM, Surveyor observed food temperatures being taken at the point of service. When DA F took the temperature of the pureed vegetables that were being kept on the steam table, it read 117 degrees. On 12/30/23 at 12:05 PM, record…

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 did not ensure that the mandatory staffing data that had been submitted from 4/1/23-6/30/23 was complete, accurate, and auditable. This has the ability to affect the census of 19. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered for Failed to have Licensed Nursing Coverage 24 Hours/Day from 4/1/23-6/30/23 for specified dates. The specified dates are as follows: FY (Fiscal Year) Q3 (Quarter 3) 2023 (April 1-June 30): 4/1, 4/3, 4/8, 4/10, 4/17, 4/19, 4/23, 4/25, 4/27, 4/29, 4/30, 5/6, 5/16, 5/20, 6/28. The facility was not able to produce the data that was submitted during this time frame for the specified dates therefore the Surveyor was not able to audit the exact document(s) that were submitted. Surveyor reviewed the facility's timecard sheets for each date that was specified in the report and all dates had licensed staff on duty for each shift. Surveyor reviewed the facility's Daily Schedule sheets for each date that was specified in 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 record review and interview, the facility did not review and revise the comprehensive care plan for falls interventions for 1 of 8 sampled residents (R), R2. This is evidenced by: The facility policy, entitled Updated Care Plans, date reviewed October 2023, stated: It is the policy of Glenhaven that the resident care plans are updated with any changes to ensure that the residents are receiving the care that is specific to their needs and wants. R2 was admitted to the facility on [DATE] and has diagnoses that include acute on chronic diastolic (congestive) heart failure, type 2 diabetes mellitus without complications, unspecified systolic (congestive) heart failure, hyperlipidemia, anxiety disorder, and depression. R2's minimum data set (MDS) assessment, dated 08/11/23, indicated that R2 had a Brief Interview for Mental Status (BIMS) score of six, meaning the resident is rarely understood. On 11/29/23 at 10:48 AM, record review of R2's most recent fall did not indicate on the care plan the interventions…

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 did not notify a provider or put nutritional interventions in place for a resident who had significant weight loss for 1 of 2 residents (R) reviewed for weight loss. (R10) R10 had a weight loss of greater than 15 pounds in the past six months and lost 10.8 pounds in the past month. The provider was not notified, and no new dietary interventions were put in place. Findings include: R10 was admitted to the facility on [DATE] with diagnoses, including in part: type 2 diabetes mellitus; chronic kidney disease, stage 2; kidney transplant; Alzheimer's disease; and bipolar disorder. On 11/28/23 at 10:53 AM, Surveyor observed R10 sitting in resident's room with breakfast tray still sitting on the over bed table. The breakfast was approximately half eaten. R10 stated she was never very hungry and thought she had lost about 20 pounds recently. On 11/28/22 at 12:30 PM, Surveyor observed R10 served a hot ham and cheese sandwich, coleslaw, sweet potato fries 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.