Las Colinas Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the plan of care for two of 35 sampled residents (Residents 12 and 162). This failure put the residents at risk for their care needs to go unmet.1.A review of Resident 12's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 12 was admitted on [DATE].During a concurrent interview and record review with RN 4 on 8/29/25 at 11:53 AM, Resident 12's Order Listing Report was reviewed. The Order Listing Report indicated Resident 12 had a peripheral IV started on 7/15/25, and the order was discontinued on 7/18/25. A review of the plan of care showed a care plan problem dated 7/15/25, for vascular access, resident at risk for complications due to the presence of a peripheral line. RN 4 stated Resident 12 did not have a current peripheral IV access line. RN 4 stated the care plan should have been revised because otherwise they are monitoring for something that is no longer an issue. 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 replace the broken hearing aids for one of 35 sampled residents (Resident 68).This failure had the potential to prevent effective communication, diminished activities of daily living and resident becoming less engaged in their overall care and well-being.During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 am, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid.A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE].A review of Resident 68's History and Physical (H&P), dated 10/2/24, indicated, hearing loss.A review of Resident 68's Inventory of Personal Effects Form dated 9/19/23 on 08/27/2025 at 6:45 AM, indicated Resident 68…

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 assist in obtaining new hearing aid for one of the 35 sampled residents (Resident 68).This deficient practice has the potential to cause a decline in Resident 68's ability to communicate and participate in social activities.During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 AM, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid.A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE].A review of Resident 68's History and Physical (H&P), dated 10/2/24, indicated, diagnoses which includes hearing loss.A review of Resident 68's Inventory of Personal Effects Form dated 9/19/23 on 8/27/2025 at 6:45 AM, indicated Resident 68 had 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 oxygen therapy was administered continuously in accordance with physician's order for one of two sampled residents investigated for oxygen treatment (Resident 141).This failure may cause Resident 141 to have difficulty breathing, potentially leading to respiratory failure.During an observation, on 8/25/25, at 2:47 PM, Resident 141 was in bed, awake, and showed no signs of pain, discomfort, or distress. An oxygen concentrator (a medical device that supplies up to 95% pure oxygen to patients through a mask or nasal tube) was noted by Resident 141's bedside. It was observed that the oxygen concentrator was turned off.During an interview with Licensed Vocational Nurse (LVN) 1, on 8/25/25, at 3:02 PM, LVN 1 stated that Resident 141's oxygen was supposed to be administered continuously. LVN 1 was asked why the oxygen concentrator was off. LVN 1 responded that the order should be reviewed to confirm if the order was continuous.During…

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

Based on observation, interview and record review the facility failed to replace e-Kits (e-Kit , a collection of prescription drugs, and related supplies, intended to provide immediate medical treatment for injuries and illnesses) in a timely manner, and to accurately complete the e-Kit Usage Slip form.This failure had the potential to delay medication administration for residents in need of emergency medical treatment. Findings:During a concurrent e-Kits inspection and interview with Registered Nurse (RN) 5 on 8/27/25 at 12:08 PM, multiple e-Kits secured with black-colored zip ties were noted. RN 5 acknowledged the findings. RN 5 stated the e-Kits that are secured with black-colored zip ties indicates a medication had been signed out and used for a resident. RN 5 explained that after a medication was signed out from an e-Kit, the licensed staff needs to inform the pharmacy about the usage of the kit. In addition, the licensed staff needs to complete an e-Kit Usage Slip form and leave a copy of the form in the e-Kit. RN 5 stated an e-Kit is usually replaced by the pharmacy within 72…

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 medications were stored in a safe manner when: 1. Loose medications were found in the medication cart,2. Expired medications were not removed and discarded from one medication room; and3. The bleach wipes were found stored together with the medications. These failures posed the risk for medication errors, cross contamination, and for medications to have lost their integrity and potency and affect the residents' health outcomes. 1. During a medication cart inspection and concurrent interview with Licensed Vocational Nurse (LVN) 5 on 8/27/25 at 12:03 PM, three loose tablets (one round, white tablet; one round pink tablet, and one round, orange tablet) were observed at the bottom of the medication cart drawer. LVN 5 was not able to identify the medications. LVN 5 stated the medications should have been discarded into the appropriate bin, if they were not administered.2. During a medication room inspection and concurrent interview with Registered Nurse (RN) 2 on 8/27/25 at 12:42 PM, a tube of Silvasorb gel…

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 reviews, the facility failed to follow its policy to provide dental assessment to one of three sample residents (Resident 1) within ninety days of admission. This failure had the potential to place Resident 1 ' s overall health and safety at risk when Resident 1 was not provided with a dental assessment to meet the needs of the resident. Findings. During a review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included, intervertebral disc degeneration, lumbar region (breakdown of one or more of the discs that separate the bone of the spine causing pain), type 2 diabetes mellitus (high blood sugar), muscle wasting and atrophy (decrease in muscle mass and strength), obstructive and reflux uropathy(problem with flow of urine through urinary tract), acute kidney failure (condition in which the kidneys suddenly can ' t filter waste from the blood) hypertension (high blood pressure).…

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 report one of four sampled residents (Resident 1) to a state agency when Resident 1 was noticed to have a blanchable redness to left side of face near left eye.This failure has the potential to affect (Resident 1) ' s health, safety and well-being. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (a condition where the brain does not function properly). A review of SBAR (document containing information about change of condition) dated 03/12/2025 indicated, . skin evaluation: abrasion . Observation summary: Resident noted to have blanchable redness to left side of face near left eye . During an interview on March 14, 2025, at 11:32 PM, with Licensed Vocational Nurse (LVN 1) the LVN 1 stated she received a report from Resident 1 ' wife that Resident 1 was complaining about water being too hot when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an accurate record of Lactulose (medication used to reduce the amount of ammonia in the blood of patients with liver disease) for one of four sample residents (Resident 1) when on January 25, 2025, at 9:00 PM, License Vocational Nurse (LVN1) did not sign on Resident 1 MAR that Lactulose was given. This failure potentially resulted in Resident 1 readmission to the hospital with ammonia level of 124 µmol/L (Micromoles per liter a unit used to measure the concentration of a substance in a solution). Normal blood ammonia level for ESRD patient is generally considered to be below 35 micromol/L. Findings: During a review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included Liver Failure (a conditions that stop the liver from working or prevent it from functioning well), End Stage Renal Failure (ESRD - a condition in which 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), had documented foley catheter monitoring was completed per shift as ordered. This failure resulted in a late entry documentation over 30 days and placed Resident 1's health and safety at risk when Resident 1 was sent out to acute hospital for further evaluation. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: hemiplegia (partial or complete paralysis on one side of body), epilepsy (nerve activity causing seizures), chronic obstructive pulmonary disease (blocking airflow, hard to breath), personal history of urinary tract infections (urine/bladder infection). During a concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. Care plan: The resident has impaired immunity r/t .sepsis…

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 follow Its policy and procedure to provide Activities of Daily Living Services (ADLS) and ensure call lights are answered in timely manner for 2 of 3 sampled residents. (Residents 1 and 3). This failure had the potential to place two clinically compromised Residents (Resident 1 and 3) ' s health and safety at risk. When the residents ' activities of daily living were not met in timely manner. Findings: During a review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that include, chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood), morbid obesity (a condition with too much body fat and results in excessive weight), heart failure (a condition that develops when the heart does not pump enough blood for the body ' s needs), and muscle wasting and atrophy (a condition with loss or thinning of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (Pressure ulcers are injury that breaks down the skin and underlining tissue. They are caused when an area of skin is placed under pressure), from developing a stage 4 pressure injury to the coccyx (tailbone area), left heel dry blister, open blister left thigh, blister to right thigh, and open blister to lower back for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk. When the facility failed to prevent the formation of pressure ulcers to Resident 1 skin. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: encephalopathy (alters brain function or structure, causes stroke, tumor .), dysphagia (difficulty swallowing), dementia (forgetfulness, impaired thinking abilities),…

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 follow policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) health and safety at risk when residents call lights were not answered promptly to assist with their activities of daily living. Findings: 1. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses that included cerebral ataxia (a disease with a symptom of an inability to coordinate balance, gait, extremities [fingers, hands, arms, legs]), and hypothyroidism (a condition that can make a resident feel tired, gain weight and be unable to tolerate cold temperatures). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental…

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 one of three sampled residents (Resident 1), was discharged home with the correct medication packs as ordered by physician. This failure contributed to a clinically compromised Resident 1 being discharged with 4 medications packs not prescribed and belonging to another resident. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: heart failure (heart does not pump blood as well), hypothyroidism (thyroid gland doesn't produce enough hormone, symptoms of fatigue, cold sensitivity, and weight gain), acute kidney failure (kidneys can't filter waste from blood). During a concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nursing (ADON) and the License Vocational Nurse (LVN 1) reviewed and verified the following: 1. Post Discharge Plan of Care: Dated April 04,…

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 follow the physician order to provide ileostomy (an opening in the belly that is made during surgery for the stool to empty out) care for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to have unmet needs, such as psychosocial and physical harm, and potentially cause skin breakdown to the ileostomy area. Findings: During a review of Resident 1's closed clinical record, the admission Record (contains demographic and medical information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of colon (abnormal growth of tissue in the large intestine), abdominal hernia (intestine or other tissue bulging out through a weakness or gap in the stomach wall) with obstruction, and anemia (condition in which the body does not have enough healthy red blood cells to provide oxygen to body tissues). Further review indicated Resident 1 was discharged from 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 observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policies and procedures (P&P) for two of four sampled Residents (Residents 1 and 3) when: 1. Hydromorphone (Dilaudid- medication used to lower pain level) was not administered to Resident 1 on August 22, 23, and 24, 2023 when pain level was documented as a seven. 2. Insulin Humalog (medication used to lower sugar level) and Insulin Glargine (medication used to lower sugar level) was not administered per physician order for Resident 3. 3. One medication cart (Cart 2), holding Resident 1's medication, did not have Hydromorphone (Dilaudid). These failures had the potential to adversely affect the health and safety of two residents (Residents 1 and 3.) Findings: 1.During a review of Resident 1's clinical record, the admission Record (contains demographic and medical information), indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses of chronic…

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 one insulin pen (an injection device with a needle that delivers insulin [medication used to lower sugar level] into the subcutaneous tissue [below the skin]) was labeled with the resident's name for one of four sampled Residents (Resident 4). This failure had the potential for the insulin pen to be administered to the incorrect resident. Findings: During a review of Resident 4's clinical record, the admission Record (contains demographic and medical information), indicated Resident 4 was initially admitted to the facility on [DATE], with diagnoses of type 2 diabetes (high sugar level), dysphagia (difficulty swallowing), and hyperlipidemia (elevated levels of fat in the blood). During a concurrent observation and interview on August 25, 2023, at 11:45 AM, with the ADON and LVN 1, LVN 1 took out an insulin pen (a pen that is prefilled with mealtime insulin) , labeled as Insulin Lispro (medication used to lower sugar level) Injection…

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 implement infection control and prevention measures when: 1. Chlorox Healthcare Bleach Germicidal Wipes (wipes used to disinfect surfaces and devices) was used by a licensed staff after its expiration date. 2. A Licensed Vocational Nurse (LVN 7) failed to perform hand hygiene when she entered rooms [ROOM NUMBERS] in the yellow zone (a designated area for symptomatic, suspected COVID-19, and residents awaiting test results; COVID-19 exposed residents; and newly admitted or re-admitted residents under observation for COVID-19 and/or with unknown COVID-19 vaccination status or declined COVID-19 vaccination) to administer medications. 3. Resident 110's peripheral intravenous catheter (PIV, a small hollow tube inserted into a vein for administration of medication, fluids, or blood products) and dressing were not replaced in accordance with the facility's policy and procedure. These failures had the potential to spread infection which can…

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 call light was accessible for one sampled resident (Resident 20). This failure had the potential for Resident 20's needs not to be met timely when she needed assistance. Findings: A review of Resident 20's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), hypertension (high blood pressure), and major depressive disorder (mental disorder characterized by depressed mood or loss of interest in activities). During a concurrent observation and interview on March 15, 2022, at 11:10 AM, with Resident 20, she was on her bed, lying on her right side. Her call light was hanging on the left side of the bed rail. She was looking for her call lights and stated, I do not know where it is [call light]. During a concurrent observation and interview 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 interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for one resident reviewed for PASRR (Resident 161). This failure had the potential for Resident 161 not to receive the care and services most appropriate for his needs. Findings: During a review of Resident 161's clinical record, the face sheet (contains demographic and medical information) indicated Resident 161 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of conditions affecting memory and…

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

Based on observation, interview, and record review, the facility failed to follow up with the physician, recommendations from Physical Therapy (PT) Services (official release from exercise treatment for strength, movement, and flexibility for those that have typically been immobilized) after discharge to Restorative Nursing Assistant (RNA) program (program designed to provide restorative and rehabilitative care for residents by using techniques to increase strength capacity and well-being) for one of one sampled residents (Resident 60). This failure had the potential to result in Resident 60 losing strength, flexibility, muscle mass, pain, skin issues, falls, and contractures (tightened muscles). Findings: During a concurrent observation and interview on March 15, 2022 at 10:08 AM with Resident 60, in Resident 60's room, Resident 60 is observed lying in bed, on back, and able to move arms. Resident 60 stated not being able to sit up at side of bed or move legs and further stated not getting any type of PT services or exercises while in bed or help with sitting up at side of bed or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standard order for house nourishment was followed as ordered by the physician. This failure had the potential to adversely affect the health and safety of Resident 86 for not receiving nutritional intervention needed for Resident 86 nutritional problems. Findings: During a breakfast observation on March 15, 2022, at 9:15 AM, Resident's diet card (slip) indicated, Diet Order: Mechanical Soft, CCHO (Controlled Carbohydrate Diet - diet prescribed for diabetic residents) Standing Order: 4 fl (fluids - unit of measurement) oz (ounces - unit of measurement) Health Shake - Nectar Thick (SUGAR FREE) and 8 fl oz Milk Nectar Thick. The Health Shake provided on the tray contained 6 grams of sugar. During an interview with the Registered Dietitian (RD), in the presence of the Dietary Supervisor (DS), on March 17, 2022, at 1:16 PM, the RD stated, The system we use don't have a choice of recording reduced sugar, we can't manually correct 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 ensure complete and accurate documentation of resident's order summary report were provided in one of two sampled residents reviewed for medical records (Resident 110). This failure had the potential for Resident 110 to receive inconsistent care coordination and unmet care needs. Findings: During an observation on March 15, 2022, at 11:40 AM, in Resident 110's room, Resident 110 was awake, calm, and comfortably lying on his bed. During a review of Resident 110's clinical record, the face sheet (contains demographic and medical information) indicated, Resident 110 was readmitted to the facility on [DATE], with diagnoses that included diabetes mellitus (condition that impairs the body's ability to process blood sugar), hypertension (high blood pressure), and osteomyelitis (swelling and infection of the bone). A review of Resident 110's Order Summary Report dated March 16, 2022, at 12:34 PM, indicated the following orders: 1. Before and…

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

Based on observation, interview, and facility document review, the facility failed to ensure the competency of supervisory staff for the kitchen when the Dietary Services Supervisor (DSS) did not know the appropriate procedure for thawing meat. This failure had the potential for the contamination of meat leading to food borne illness for 167 residents who ate food from the kitchen out of a facility census of 181. Findings: During an observation and concurrent interviews with [NAME] 2 and the DSS, on May 21, 2019, at 2:30 PM, multiple, 5-pound tubes of ground meat were in a sink, with water running into the sink. Five ground meat tubes that sat on top of other ground meat tubes were not fully submerged in the water. [NAME] 2 stated the meat was being thawed to cook tomorrow for lunch. When the DSS was asked if the way the meat was thawed in the sink was the correct process, she stated yes. She stated it was okay if the meat was not fully submerged as long as the water was running over it. It was observed that the water did not run over all the meat that was not submerged 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.

Based on observation, interview, and facility document review, the facility failed to ensure the competency of staff when: 1. A cook did not use appropriate procedures to ensure food was served at a safe temperature; and 2. A cook was not able to demonstrate appropriate procedures for calibrating a thermometer. This failure had the potential for food to be served at an unsafe temperature and lead to food borne illness for 167 residents who received food from the kitchen out of a facility census of 181. Findings: 1. An observation and concurrent interviews on 5/20/19 at 11:48 AM, with [NAME] 1 and the Director of Food and Nutrition Services (DFNS), showed [NAME] 1 measured temperatures of food on the tray-line before food service. When she took the temperature of a large pan of green beans, she placed the calibrated thermometer probe into the green beans close to the side of the pan. Her thermometer read 168.9 degrees Fahrenheit (F). She wrote down the temperature on the temperature log sheet, then moved to the next food to take a temperature. When the surveyor measured 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 facility record review, the facility failed to cook vegetables in a way to preserve the nutritional content and palatability, when frozen vegetables were left to cook in the oven 2 to 3 hours before serving. This failure had the potential to decrease the nutritive content and palatability in the vegetables and result in a nutrition deficiency for 167 residents who consumed food from the kitchen, out of a facility census of 181 residents. Findings: During an observation and concurrent interview with [NAME] 1, on May 20, 2019, at 9:03 AM, pans covered with foil were observed in the oven. [NAME] 1 stated she had carrots and green beans cooking. She stated they were frozen vegetables and she would cook them for about 2 hours. During an observation and concurrent interview with [NAME] 1, on May 22, 2019, at 9:30 AM, pans covered with foil were observed in the oven. [NAME] 1 stated the only thing she had in the oven was frozen spinach, and she placed it in the oven before her break at about 8:20 AM. She stated she would cook the spinach for 2 to 3…

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 facility record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service to follow safe food handling and sanitation when: 1. The inside of the ice machine was not clean; 2. Staff personal clothing was stored in an area with single use food service items; 3. Cooking equipment was stacked and stored wet; 4. A food storage cabinet was not clean; and 5. Food preparation tools were not clean and stored in a wooden box that was not clean. These findings had the potential to cause contamination of food leading to food borne illness for 167 residents who received food from the kitchen out of a facility census of 181 residents. Findings: 1. During an observation and concurrent interview with the Property Services Director (PSD) and the Director of Food and Nutrition Services (DFNS), on May 20, 2019, at 11:20 AM, the PSD opened the ice machine for the surveyors to view inside. The plastic cover that covered the top opening of the ice machine had black dotted residue on the inside…

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 facility document review, the facility failed to have a policy for storing food safely that was brought in by family and visitors. This failure did not allow residents to have food brought in by family and visitors stored safely for them to eat at a later time for 167 residents that consumed food by mouth out of a facility census of 181. Findings: Review of the undated facility policy titled Food Receiving and Storage read 3. Residents must consume foods from sources not procured by the facility within the same day of receiving to prevent food borne illness. Any unused food should be disposed of immediately thereafter. In an interview on 5/21/19 at 4:21 p.m., Certified Nursing Assistant 2 (CNA 2) stated family members brought in food but it was not kept and that the residents had to eat it right away. In an interview on 5/21/19 at 4:23 p.m., CNA 3 stated food brought in by family members was not stored. If the residents did not eat it right away it was thrown away. In an interview on 05/21/19 4:31 p.m., the DON stated the facility staff encouraged residents 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 3. During an observation and concurrent interview, on May 20, 2019 at 3:53 PM, with Resident 179, a plastic covered container of pineapple dated 5/20, and a second plastic covered, manufactured mixed fruit cup containing pineapple, was on Resident 179's over-bed table. Resident 179 stated she required assistance to eat, as she was not able to open the snack containers. Resident 179 further stated she could not eat the fruit cup snacks provided by the staff (the resident did not recall the name of the staff who placed the pineapple cup), as she identified pineapple in both cups, and was allergic to pineapple. During an observation and concurrent interview, on May 20, 2019 at 4:04 PM, with the Certified Nurse Assistant/Restorative Nurse Aide 1 (CNA/RNA 1,) she confirmed the mixed fruit cup on Resident 179's over-bed table contained pineapple and removed it from the resident's table. CNA/ RNA 1 further stated Resident 179 should not have the mixed fruit cup, as it contained pineapple and Resident 179 was allergic…

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 accurately complete two annual RAI-MDS assessments (The Resident Assessment Instrument - Minimum Data Set (RAI-MDS) is the standardized assessment tool for admission, quarterly, significant change in health status and annual assessments for each resident,) under neurological diagnoses for Resident 160. This failure had the potential for inappropriate or insufficient provision of dementia-related care for one resident (Resident 160) in a universe of 35 vulnerable sampled residents. Findings: During an observation on May 20, 2019 at 10:16 AM, Resident 160 was observed in her wheelchair, and spoke Portuguese with little understanding of English and some understanding of Spanish. During a review of Resident 160's clinical record on May 22, 2019 at 3:40 PM, the PASRR (Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care,) dated February 21, 2019, with admission date of March 15, 2017, 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 observation, interview, and record review, the facility failed to ensure a hemodialysis (the process of removing waste products and excess fluid from the body) access site (AV shunt site - a surgical connection made between an artery and a vein for hemodialysis) dressing was removed and kept visible for the staff to observe any potential bleeding after dialysis treatment affecting one of three sampled residents (Resident 55). The facility did not follow the physician's order to remove the resident's left AV shunt dressing four hours after dialysis. This failure had the potential to affect the resident's health and safety. Findings: A clinical record review of Resident 55's face sheet (demographic information) indicated Resident 55 was admitted on [DATE] with diagnosis that included end stage renal disease (a condition where the kidneys fail to function and requires the use of a hemodialysis machine to act as an artificial kidney to clean the resident's blood from toxins) and an AV shunt to the left arm…

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.