Continuing Healthcare At Cedar Hill

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure laboratory testing for a comprehensive metabolic panel (CMP) and lipid panel were obtained in the month of June 2026, as ordered by the physician. This affected one (Resident #1) of five residents reviewed for unnecessary medications. Findings include:Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease (ASHD) and heart failure. Review of Resident #1's physician's orders revealed the resident was to receive Atorvastatin (a cholesterol lowering medication) 40 milligrams (mg) by mouth (po) every night at bedtime for hyperlipidemia (high cholesterol in the blood). The order originated on 04/08/26. The resident was also receiving Furosemide (a potassium depleting diuretic) 40 mg po twice a day and Potassium Chloride Extended Release (ER) 20 milliequivalents (meq) po every morning for hypokalemia (low potassium level in the blood). The physician's orders…

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 staff interview, the facility failed to clean dishes in a safe and sanitary manner. This affected all 79 residents residing at the facility. Findings include:Observation on 06/29/26 at 10:02 A.M. with Regional Dietary Manager #468 of the dishwasher cycles revealed wash temperature of 160 Fahrenheit (F) and rinse temperature of 150 F. She ran five more cycles and temperatures still did not meet minimum requirements.Review of the dishwasher logs for December 2025 revealed on 12/26/25 the breakfast wash cycle was 138 F.No dishwasher logs for January 2026.Review of the dishwasher logs for February 2026 revealed wash cycles on 02/01/26, 02/02/26, 02/04/26, 02/05/26, 02/07/26, 02/09/26, 02/10/26, 02/12/26, 02/15/26, 02/16/26, 02/17/26, 02/18/26, 02/19/26, 02/21/26, 02/22/26, 02/24/26, 02/26/226 did not meet minimum temperature requirement of 150 F.No dishwasher logs for March 2026.Review of the dishwasher logs for April 2026 revealed wash cycles on 04/22/26 did not meet minimum requirement of 150 F; and rinse cycles on 04/03/26 and 04/22/26 did not meet minimum…

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, record review, staff interview, and facility policy review, the facility failed to maintain infection prevention and control practices when staff failed to use proper personal protective equipment while providing care for one resident (#11), with the potential to affect 13 additional residents (#1, #3, #16, #17, #19, #22, #28, #33, #39, #51, #55, #61, and #84) who received care from the same staff; and failed to ensure newly hired staff completed required two-step Mantoux/tuberculosis screening upon hire for two of 13 employee files reviewed, Social Services Director #450 and Nursing Scheduler #366. The facility census was 79. Findings Include:1: Interview with the Human Resources Director #150 was conducted on 07/01/26 from 8:00 A.M. to 8:45 A.M. regarding staffing file review, employee health requirements, and Mantoux/TB screening documentation. Review of employee health screening documentation revealed Social Services Director #450 had a hire date of 11/28/25. Review of the employee file…

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 medical record review, policy review and interview, the facility failed to ensure residents received specialized therapy services as written in the plan of care. This affected one resident (#60) of three residents reviewed for specialized therapy services. The census was 77.Findings include:Medical record review revealed Resident #60 was admitted on [DATE] with diagnoses including wedge compression fracture of second lumbar vertebra, unspecified dementia, unsteadiness on feet, muscle weakness, cerebral infarction, anxiety and difficulty in walking not elsewhere classified. Review of the Physical Therapy (PT): Plan of Treatment and Orders revealed therapy services were initiated on 08/21/25. The PT plan of treatment certification periods included 09/19/25 through 10/18/25; 10/15/25 through 11/13/25, 11/14/25 through 12/06/25, and 12/06/25 through 01/04/26. The services were to be provided three to five times a week for therapeutic exercises, therapeutic activities, neuromuscular reeducation, and gait…

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, record review, interview, and policy review, the facility failed to ensure Resident #54 received necessary services to maintain good oral hygiene. This affected one (Resident #54) of three residents reviewed for activities of daily living (ADL) care. The facility census was 71. Findings include:Review of Resident #54's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included major depressive disorder, muscle weakness, unsteadiness on his feet, abnormalities of gait and mobility, and the need for assistance with personal care. Review of Resident #54's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors, nor was he known to reject care. He was coded as being dependent on staff for oral hygiene. He was indicated to be edentulous with no natural teeth or tooth fragments noted. Review of Resident #54's care plans revealed he 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview the facility failed to follow physician orders to apply ice packs several times a day to the left knee of Resident #72 who was status post left total knee replacement. This affected one (Resident #72) of three residents reviewed for admission and post-surgical physician orders. The facility census was 71. Findings Include:Findings Include:Review of the medical record for Resident #72 revealed an admission date of 10/16/25 after having a left total knee replacement on 10/13/25. Resident #72's diagnoses included diabetes, anemia, heart disease, high blood pressure and gastric reflux.Review of the initial nursing assessment completed on 10/16/25 revealed Resident #72 had a brief interview for mental status score of 14/15, meaning the resident was cognitively intact. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #72 was dependent for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain the facility in good repair and maintain a home like environment. This affected 12 of 41 resident rooms currently occupied by residents in the facility. The resident census was 70.Findings Include: On 09/18/25 tour of the facility between 9:50 A.M. and 10:20 A.M. the following environmental issues were observed: 1. room [ROOM NUMBER] behind the bed by the window, the wall was gouged and the paint peeling.2. room [ROOM NUMBER] the wall was patched and not painted in multiple places.3. room [ROOM NUMBER], 105 and 201 the ceiling was peeling and hanging down.4. room [ROOM NUMBER] by the bathroom door and corner by the dresser was gouged and scraped.5. The wallpaper was torn on both sides of the door by room [ROOM NUMBER].6. Between room [ROOM NUMBER] and room [ROOM NUMBER] the wallpaper was torn.7. room [ROOM NUMBER] the wall behind and beside the bed had gouges in multiple places.8. Baseboard was missing in the hallway by room [ROOM NUMBER]…

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

Based on observation, staff interviews, and review of facility policy, the facility failed to store perishable items under sanitary conditions. This had the potential to affect all 85 residents residing in the facility. All residents were identified as receiving meals from the kitchen. Findings include: Observations of the walk in freezer on 01/21/25 at 8:18 A.M. revealed several undated/unlabeled items which were later identified by Dietary [NAME] #205 as follows: four bags of hash browns removed from their original packaging and now stored in a two-gallon plastic storage bags, a bag of tater tots removed from their original packaging which had been opened and were now stored in a two-gallon plastic storage bag, one bag of chicken tenders removed from their original packaging and now stored in a two-gallon plastic storage bag, three bags of frozen drumsticks removed from their original packaging and now stored in two-gallon plastic storage bags, five bags of Hawaiian rolls and two of which had been previously opened, one previously opened bag of cinnamon rolls which were stuck…

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

Based on observation, staff interview, and review of the shower cleaning sheets, the facility failed to maintain a clean and sanitary shower room. This affected all 45 residents (#3, #7, #11, #13, #14, #15, #18, #19, #20, #22, #23, #25, #26, #27, #30, #35, #36, #40, #41, #42, #43, #45, #46, #47, #49, #52, #59, #61, #62, #63, #64, #67, #69, #72, #73, #75, #79, #232, #233, #234, #236, #237, #282, #332, and #334) residing on the east wing of the facility who utilized the facility's shower room. The facility census was 85. Findings include: Observation on 01/21/25 at 11:40 A.M. of the facility's East Wing shower room revealed the room hosted two shower stalls. One stall was clear while the other stall hosted several shower chairs. Along the shower wall of the second shower stall was a moderate amount of green residue. Review of the Shower Cleaning Sheet revealed housekeeping staff were to clean shower rooms on Mondays, Wednesdays, and Fridays. The cleaning involved cleaning the sink, stocking soap and paper towels, disinfecting the tub, sweeping and mopping the floors, cleaning the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, and record review, the facility failed to provide unopened mail for Resident #41. This affected one resident (#41) out of one resident reviewed for privacy. Findings included: Review of the medical record revealed Resident #41 was re-admitted on [DATE] with diagnoses that included type two diabetes mellitus with diabetic neuropathy, heart disease, obstructive and reflux uropathy, conduct disorder, chronic osteomyelitis, heart failure, major depressive disorder, dementia, suicidal ideation, depression, and hypertension. Review of the annual minimum data set (MDS) 3.0 dated 09/06/24 revealed Resident #41 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. Resident #41 had no impairment of functional range of motion in upper or lower extremities and reported no pain and received no pain medication. Review of Resident #41's admission agreement dated 02/20/19 revealed he wished to receive his mail unopened. Interview on 01/21/25 at…

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

Based on record review and staff interview, the facility failed to correctly identify Resident #52's psychotropic diagnosis on a significant change Preadmission Screening and Resident Review (PASRR) form. This affected one resident (#52) out of one resident sampled for PASRR. The facility census was 85. Findings include: Review of Resident #52's medical record revealed an admission date of 09/29/23 and diagnoses including traumatic subdural hemorrhage with loss of consciousness of unspecified duration, bipolar disorder, major depressive disorder, and anxiety. Review of Resident #52's physician orders revealed the resident was ordered Celexa 40 milligrams (mg) in the morning for yelling out/restlessness, Depakote Delayed Release 125 mg three times daily for bipolar disorder, and Lorazepam 2 mg/milliliter (ml) with instructions to administer 0.5 ml every four hours as needed for anxiety/agitation for 90 days. Review of Resident #52's care plan dated 10/13/23 revealed the resident utilized psychotropic medications related to bipolar disorder with interventions to monitor for target…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, record review, and policy review, the facility failed to ensure Resident #32 was provided the opportunity to participate in and attend his quarterly care conference meeting. This affected one (Resident #32) out of six residents reviewed for care planning. The facility census was 85. Findings include: Review of the medical record for Resident #32 revealed an admission date for 03/27/24. Diagnoses included diabetes mellitus type two, retention of urine, and major depressive disorder. Review of Resident #32's Interdisciplinary Care Conference Summary dated 12/16/24 revealed no signatures were present on the form, indicating the interdisciplinary team (IDT) members and the resident were not present for the meeting. Review of Resident #32's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact. Interview on 01/21/25 at 1:02 P.M. Resident #32 revealed he had not had a care plan meeting since his admission to the facility (March…

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 review of resident medical records, staff interviews, and review of facility policy, the facility failed to provide appropriate care and services related to a significant weight loss for Resident #17. This affected one (Resident #17) of six residents (Resident #1, #12, #17, #32, #57, and #134) reviewed for nutrition. The facility census was 85 residents. Findings include: Review of the medical record revealed Resident #17 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified dementia, and anxiety disorder. Review of the care plan dated 07/30/24 revealed Resident #17's had a nutritional problem or a potential nutritional problem related to chronic disease, was at risk for malnutrition, and was using a mechanically altered diet and thickened liquids. The interventions included to monitor and record signs and symptoms of malnutrition, including significant weight loss of over five percent (%) in one month, the dietitian was to evaluate and make diet change…

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

Based on observations, medical record review, resident interview, staff interview, and facility policy/procedure review, the facility failed to maintain a sanitary living environment. This affected one resident (#68) of three residents reviewed for a sanitary living environment. The facility census was 75. Findings include: Observations on 05/29/24 at 10:30 A.M. and 10:45 A.M. revealed mouse droppings in a basket in Resident #68's bedroom. The basket had personal items in it, as well as a box of snack cakes (each individual cake was sealed). Resident #68 was admitted to the facility 11/24/22 with diagnoses including type II diabetes, chronic obstructive pulmonary disease, vascular dementia, need for assistance with personal care, difficulty walking, dysphagia, cerebral aneurysm, autonomic neuropathy, insomnia, ventral hernia, hyperlipidemia, depression, obesity, atrial fibrillation, hypothyroidism, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 03/01/24, revealed Resident #68 was cognitively intact. Interview with Resident #68 on 05/29/24 at 10:35 A.M.…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, record review and facility investigation review the facility failed to prevent Resident #20 from exiting the facility without staff assistance. This affected one resident (Resident #20) of three residents reviewed for accidents. The facility census was 80. Finding include: Review of the medical record for Resident #20 revealed an admission date on 06/09/23. Diagnosis included unspecified dementia, anxiety, and encephalopathy. Review of Resident #20's physician order dated 06/26/23 revealed the resident had a wanderguard (a magnetized fob that is placed on the wrist or ankle to alert staff when a resident is exiting an alarmed door) placed on her ankle and for placement to be checked every shift. Review of Resident #20's Care Plan revealed the resident was a risk for elopement related to impaired cognition, wandering, a history of attempting to leave the…

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

Based on observation, staff interview, and facility policy review for food storage and hand hygiene, the facility failed to ensure food was properly stored and meal trays were prepared in a sanitary manner. This affected all residents residing in the facility at this time. The facility census was 77. Findings include: Observation on 07/10/23 at 8:11 A.M. revealed during initial tour of the kitchen, there were bags of food located in the walk-in freezer that was not properly sealed. There was one bag of breaded chicken tenders, one bag of tater tots, and one bag of french fries. All three bags were noted to be open with the food exposed to the open air. Interview on 07/10/23 at 8:50 A.M. with Dietary Manager #342 confirmed the three open bags of food. Dietary Manager #342 also confirmed any food stored in the freezer needed to be properly sealed to protect the food from the freezer air. Review of facility's policy titled Food Storage, revised 09/08/2021 revealed, all food stock and products are stored in NSF approved sanitary storage container, of food quality plastic bags, covered,…

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 ensure the clean laundry room, which had a gas powered dryer, had a carbon monoxide detector. This had the potential to affect all 77 residents residing in the facility. Findings included: Observation on 07/13/23 at 8:30 A.M. of the clean laundry room revealed there were two dryers, one electric powered and one gas powered. Further observation revealed no carbon monoxide detector in the laundry room. Interview on 07/13/23 at 8:40 A.M. with Housekeeping Staff #347 revealed she had never seen a carbon monoxide detector in the clean laundry room with the gas dryer. Interview on 07/13/23 at 9:00 A.M. with Maintenance Staff #418 verified the UniMac dryer was a gas powered dryer and there was no carbon monoxide detector in the room. He also verified there should be a carbon monoxide detector in the room, and he didn't know how he missed it. Review of the facility Carbon Monoxide Detector Monitoring Log revealed there was no carbon monoxide detector in the laundry room with the gas dryer.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure Resident #42 was treated with dignity and respect. This affected one resident (#42) of two residents reviewed for dignity. The facility census was 77. Findings included: Review of Resident #42's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, type two diabetes mellitus without complications, lymphedema, and essential hypertension. Review of Resident #42's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/23, revealed she was cognitively independent. Observation on 07/10/23 at 11:06 A.M. and 3:30 P.M. and 07/11/23 at 8:11 A.M. revealed a paper sign on Resident #42's door stating, (resident's proper name) has right arm lymphedema and cannot have blood pressure taken or blood drawn from this arm! (Resident's proper name) also has a port in her chest from previous chemotherapy. Please be careful not to bump! Thank you!. Observation 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 medical record review, and staff interview, the facility failed to ensure each residents Minimum Data Set (MDS) accurately reflected the use of antipsychotic medication or reflected the contraindication for a gradual dose reduction (GDR) for that antipsychotic. This affected two residents (Resident #42, and #50) of the 20 residents reviewed for accurate MDS. The facility census was 77. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date of 12/22/2020. Diagnosis included Alzheimer disease, bipolar disorder, major depressive disorder, dementia with behavioral disturbances, and mood affective disorder. Review of Resident #42's physician orders revealed a order dated 12/2020 for Perphenazine (antipsychotic) 2 milligrams (mg) twice a day for bipolar disorder. Review of the plan of care dated 01/03/2021 and revised 10/31/2022 revealed Resident #42 was at risk of adverse reactions related to depression, the use of psychoactive medications, and an affective mood…

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 medical record review, staff interview, and review of facility policy for preadmission screening and resident review (PASRR), the facility failed to ensure a new PASRR was submitted for residents with a new mental health diagnosis. This affected two residents (Resident #38, and #23) of the two residents reviewed for accurate PASRR assessments. The facility census was 77. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 05/22/2019. Diagnoses included anxiety disorder, depressive disorder, protein-calorie malnutrition, and schizoaffective disorder. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Review of Resident #38's most recently completed PASRR dated 06/17/2019 revealed under Section D, indications of serious mental illness, the diagnosis schizophrenia was the only diagnosis marked for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a resident who was on fluid restriction had fluid intake monitored and documented. This affected one Resident (#24) of one resident reviewed for nutrition. The facility census was 77. Findings included: Review of Resident #24's medical record revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, essential hypertension, and generalized muscle weakness. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/10/23, revealed she was slightly cognitively impaired and had active diagnoses of renal insufficiency, renal failure and end stage renal disease. Further review revealed she was independent with setup help only for eating. Review of Resident #24's MDS timeline revealed she was out of the facility from…

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, record review, and facility policy review, the facility failed to ensure a resident who was receiving hemodialysis was assessed prior to and upon return from dialysis and there was communication between the facility and the dialysis center. This affected one resident (#24) of one resident reviewed for dialysis. The facility census was 77. Findings included: Review of Resident #24's medical record revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, essential hypertension, and generalized muscle weakness. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/10/23, revealed she was slightly cognitively impaired and had active diagnoses of renal insufficiency, renal failure and end stage renal disease. Further review revealed she received dialysis prior to and while being 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 medical record review and staff interview, the facility failed to ensure antibiotics were not prescribed prior to receiving lab testing results and prescribed appropriately according to lab testing results. This affected one (Resident #23) of five residents reviewed for antibiotic use. The facility census was 77. Findings include: Review of Resident #23's medical record revealed an admission date of 01/19/23 with diagnoses that included cerebrovascular accident with hemiplegia and obstructive and reflux uropathy. Review of Resident #23's progress notes revealed on 04/27/23 the resident was transferred to the local emergency room (ER) for evaluation. Resident #23 returned to the facility on [DATE] after ER evaluation with a diagnosis of urinary tract infection (UTI) and new orders for cefdinir (antibiotic) 300 milligrams (mg) twice daily for seven days. A urinalysis with culture and sensitivity was obtained at the ER during evaluation. The urinalysis with culture and sensitivity was completed 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.