Dallas Retirement Village Health Center

Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and quality of life. Findings include: On 7/31/23 at 12:20 PM the 6/8/23 Facility Assessment was reviewed. The assessment was not comprehensive and did not include information on the following: -Facility staffing levels; -Staff competencies that were necessary to provide the level and types of care needed for the resident population; -Ethnic or cultural factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services; -The facility's resources, including but not limited to all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; and contracts, memorandums of understanding. On 7/31/23 at 12:30 PM Staff 1 (Administrator) reviewed…

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, it was determined the facility failed to have policies and procedures in place in the event of a facility closure for 1 of 1 sampled facility. This placed residents at risk for displacement. Findings include: On 7/31/23 the facility was asked to provide a policy and procedure in the event of a pending or potential facility closure. On 7/31/23 at 11:31 AM Staff 1 (Administrator) stated the facility did not have a policy and procedure for pending or potential facility closure.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide a qualified social service worker. This placed all residents at risk for unmet medically related emotional and social service needs of the residents. Findings include: The Facility assessment dated [DATE] revealed the following information regarding qualifications for the Social Service Director: -(A) Have bachelor's or master's degree in behavioral sciences with at least on years' experience in a health care setting; or -(B) An associate degree in behavioral sciences with two years' experience in a health care setting; or -(C) Receive regular on-site consultation, no less often than quarterly, from an individual who has a bachelor's or master's degree in social work or related behavioral science, and one year's experience in a long-term care setting working directly with individual resident, and have written procedures for referring resident in need of social services to appropriate resources; -The Social Service Director of 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.

Based on observation, interview, and record review it was determined the facility failed to honor resident dining room choices and preferences for 3 of 3 sampled residents (#s 22, 37 and 50) reviewed for honoring choices. This placed residents at risk for increased isolation, lack of socialization and lack of self-determination. Findings include: Review of Resident Council Minutes revealed the following: 4/19/22: -Residents aired their concerns about D Hall Pantry/Dining Room closing and having to eat in the main dining room. -Too far for CNAs to travel, if something was forgotten on the meal tray. -Meals were delivered late. -Too much was expected from the CNAs so they were unable to do their job well. -Main dining room was loud, socializing was difficult, not a nice place to enjoy a meal and with so much going on and so many people crammed into a small space. -Resident 22 wrote concerns regarding the D Hall Pantry/Dining Room which revealed the following: -There is a sign in the front that states Residents Do Not Live in Our Facility. We Work in Their Home. -Lately residents felt…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to maintain and provide a clean homelike environment for 4 of 6 halls reviewed for environment. This placed residents at risk for living in an unclean and an unhomelike environment. Findings include: On 7/24/23 and 7/28/23 the following observations were made: -room [ROOM NUMBER]: Had a dark black stain which measured approximately one foot by one and a half feet across and adjacent to the stain was another black stain which measured approximately six inches by one foot across. -room [ROOM NUMBER]: Had a dark black stain which measured approximately seven inches by 19.5 inches across, adjacent to that was two smaller black spots the size of approximately two silver dollars. -room [ROOM NUMBER]: Had a dark black stain which measured approximately one foot four inches by six inches wide. -room [ROOM NUMBER]: Had huge gouges in the wall behind the recliner with sheet rock exposed. The wall heater was partially disconnected from the wall 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 it was determined the facility failed to ensure food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchen and for 4 of 4 sampled residents (#s 17, 22, 47 and 50) reviewed for food service. This placed residents at risk for food that was not palatable or appetizing. Findings include: Interview with residents indicated the following: -On 7/24/23 at 11:50 AM Resident 50 stated the food was not always hot. Resident 50 stated the food was not great tasting and lacked quality. -On 7/24/23 at 12:09 PM Resident 17 stated the food was terrible and she/he often refused to eat it. Resident 17 stated the food was served cold most of the time. -On 7/24/23 at 2:49 PM Resident 47 stated the food was terrible and cold when it was delivered. -On 7/25/23 at 10:16 AM Resident 22 stated she/he ate in her/his room and experienced cold food by the time it arrived to her/his room. Resident 22 stated when they had the smaller dining room staff were able to warm up food in the microwave but now staff had to walk…

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 it was determined the facility failed to ensure records were complete and accurate for 5 of 8 sampled residents (#s 30, 32, 47, 58 and 89) reviewed for medications, dialysis and planned discharge. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 58 admitted to the facility in 3/2023 with diagnoses including Chronic Kidney Disease. Resident 58's Care Plan dated 4/6/23 revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week outside the facility. On 7/26/23 at 1:32 PM Staff 11 (Agency/CNA) stated he did not know where Resident 58's dialysis fistula (a surgical connection between an artery and a vein) was located and used the resident's legs for blood pressures. On 7/27/23 at 8:13 AM Staff 37 (Agency/RN) stated he thought Resident 58's dialysis fistula was in her/his left upper extremity. On 7/27/23 at 8:28 AM Resident 58 stated staff did not monitor her/his dialysis catheter in her/his neck. Observation of…

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

Based on interview and record review it was determined the facility failed to treat a resident with dignity for 1 of 1 sampled resident (#47) reviewed for dignity. This placed residents at risk for lack of dignity and quality of life. Findings include: Resident 47 was admitted to the facility in 2023 with diagnoses including PTSD (Post-Traumatic Stress Disorder), anxiety disorder and depression. Resident 47's 6/11/23 Quarterly MDS indicated a moderately severe score for depression. Resident 47's 6/12/23 Care Plan for psychosocial well-being indicated staff were to involve the resident in all aspects of care to encourage resident empowerment. A Progress Note dated 7/18/23 indicated the resident complained of itching in her/his private genital area. A physician's order was received for the resident to be administered Diflucan (anti-fungal medication) orally one time a day for three days for the yeast infection. Resident 47's provider progress note dated 7/27/23 indicated Resident 47 continued to experience genital discomfort and itchiness. A physical exam was performed and 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 and interview the facility failed to ensure residents were treated with respect for their personal possissions for 1 of 1 sampled resident (#56) reviewed for choices. This placed residents at risk for lack of respecting private belongings. Findings include: Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke. On 7/24/23 at 12:16 PM Resident 56 stated on multiple occasions she/he requested for staff to ask permission before they retrieved something from her/his nightstand. Resident 56 stated staff continued to retrieve items from her/his nightstand without asking and this was very upsetting because it's my private stuff! Resident 56 was observed to be anxious and tearful when she/he expressed the concern. The night stand had the top drawer opened approximately four inches and the resident's personal items were visible inside the drawer. On 7/27/23 at 10:31 AM Staff 21 (LPN) stated Resident 56 had concerns regarding staff opening and grabbing things out of her/his nightstand without asking. Staff 21 stated the resident was upset…

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 it was determined the facility failed to obtain copies of Advance Directive for 1 of 4 sampled residents (#5) reviewed for Advance Directives. This placed residents at risk for lack of end of life choices being honored. Findings include: Resident 5 was admitted to the facility in 2023 with diagnoses including UTI and muscle weakness. Resident 5's 5/23/23 admission MDS indicated she/he was cognitively intact. Resident 5's 5/23/23 Health Center admission Agreement indicated the resident had an Advance Directive. Resident 5's 6/6/23 Care Conference Note indicated the resident's Advance Directive was not reviewed. Resident 5's clinical record revealed there was no copy of her/his Advance Directive. On 7/26/23 at 11:00 AM Staff 16 (Social Service Director) stated upon admission residents were asked if they had an Advance Directive and if so to provide a copy. Staff 16 stated if a copy of the resident Advance Directive was not provided on admission, her process was to follow-up within a few days to obtain a copy. Staff 16 stated she did not follow-up…

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 it was determined the facility failed to ensure residents were informed in writing of Advance Beneficiary Notification (ABN) for 1 of 4 sampled residents (#98) reviewed for discharge. This placed residents at risk for financial hardship. Findings include: Resident 98 admitted to the facility with Medicare Part A services on 5/30/23. The resident's last covered day of Medicare Part A services was 7/7/23. A 7/5/23 progress note indicated Staff 22 (Social Services Assistant) provided a NOMNC (Notification of Medicare Non-Coverage) to Resident 98 and the resident was informed if she/he did not discharge by midnight on 7/8/23 she/he would be charged $455 a day. There was no evidence in the clinical record to indicate a written Advanced Beneficiary Notification (ABN) was provided to explain the financial responsibilities for Resident 98. On 7/28/23 at 9:51 AM and 12:30 PM Staff 22 stated she provided Resident 98 with the NOMNC and verbally explained the daily cost rate if the resident were to remain in the facility. Staff 22 stated if an ABN was…

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 it was determined the facility failed to ensure a resident grievance was addressed for 1 of 2 sampled residents (#76) reviewed for personal property. This placed residents at risk for unresolved concerns and loss of personal property. Findings include: Resident 76 was admitted in 6/2023 with diagnoses including cancer. On 7/24/23 at 10:23 AM Resident 76 stated she/he was missing a crocheted bed spread and a green night gown for over a month. Resident 76 stated she/he reported the missing items and staff did not follow up. The 7/17/23 grievance form filled out by Resident 76's family member indicated the resident was missing a crocheted blanket (missing for two months) and a green night gown (missing for one month). The bottom of the grievance was not completed and there was no indication there was a resolution to the grievance as of 7/27/23. On 7/27/23 at 1:33 PM Staff 16 (Social Service Director) acknowledged Resident 76's 7/17/23 grievance indicated the crocheted blanket and night gown were missing for one or two months. Staff 16 stated 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 it was determined the facility failed to safe, resident-centered discharges for 2 of 4 sampled residents (#s 5 and 98) reviewed for discharge. This placed residents at risk for unmet care needs after discharge. Findings include: 1. Resident 98 admitted to the facility on [DATE] and discharged on 7/8/23 with diagnoses including respiratory failure and fibromyalgia (widespread muscle pain). A concern was reported to the State Agency on 7/11/23 which indicated Resident 98 was approved to stay at the facility under Medicaid after her/his skilled days ended. Facility staff informed Resident 98 if she/he did not discharge by 7/8/23 she/he would be charged $500 a day. Resident 98 discharged home on 7/8/23. Resident 98 was referred to a home health agency which she/he requested to not use. Review of progress notes revealed the following: -6/12/23 Resident 98 informed Staff 16 (Social Services Director) that she/he was unsure if she/he was ready to discharge home and needed more time…

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 it was determined the facility failed to complete a discharge summary for 1 of 4 sampled residents (#89) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 89 was admitted to the facility in 6/2023 with diagnoses including stroke. The resident discharged home on 7/17/23 on a resident initiated discharge. A review of Resident 89's medical record indicated there was no discharge summary documentation. On 7/31/23 at 11:13 AM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 89.

Based on observation, interview and record review it was determined the facility failed to follow physician orders and implement bowel care for 2 of 2 sampled residents (#s 24 and 249) reviewed for choices and constipation. This placed residents at risk for increased pain. Findings include: 1. Resident 24 admitted to the facility in 2015 with diagnoses including constipation. The 7/20/23 care plan indicated Resident 24 required extensive assistance for toileting. The 6/14/23 physician orders indicated Resident 24 was to receive the following: -Fiber-Stat liquid give 30 ml PO every 12 hours PRN constipation. -Milk of Magnesia (MOM) 400 mg/5 ml give 30 ml PO PRN constipation once daily. -bisacodyl suppository 10 mg insert one suppository rectally PRN for constipation once daily. Resident 24's 6/2023 and 7/2023 bowel records revealed the following days with no bowel movements: -7/3/23; 7/4/23; 7/5/23; 7/6/23 and 7/7/23 (five days). -7/9/23; 7/10/23; 7/11/23; 7/12/23; 7/13/23 and 7/14/23 (six days). There was no indication Resident 24 received or refused the ordered bowel medications 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.

Based on observation, interview and record review it was determined the facility failed to ensure treatment and services to maintain vision abilities were provided for 1 of 1 sampled resident (#56) reviewed for vision. This placed residents at risk for impaired vision. Findings include: Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke. On 7/24/23 at 12:32 PM Resident 56 was observed wearing glasses and the right side of the glasses was wrapped in blue string to hold them together. Resident 56 stated she/he wore glasses all the time in order to see and the glasses were broken for greater than a month and staff were aware. Resident 56 stated first staff tried to glue the right side of the glasses together and then used string to fix the glasses. No evidence was found in the clinical record regarding Resident 56's broken glasses or any indication vision services were initiated or new glasses were ordered. On 7/26/23 at 11:28 AM Staff 21 (CNA) stated Resident 56 wore glasses all the time in order to see and her/his glasses were broken three different…

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, record review and interview it was determined the facility failed to ensure oxygen equipment was properly maintained for 1 of 2 sampled residents (#32) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 32 was admitted to the facility in 9/2019 with diagnoses including COPD (chronic obstructive pulmonary disease). Multiple observations from 7/25/23 through 7/28/23 revealed Resident 32 used a high-flow oxygen concentrator (oxygen supply system delivering 100% humidified and heated oxygen) through a nasal cannula (lightweight tubing with two prongs placed in nostrils). Resident 32's physician orders dated 6/9/23 indicated: -to use oxygen as needed via the nasal cannula to keep oxygen level at 90%. -change humidification bottle and tubing on concentrator every three days on night shift and date the bottle and tubing when done. -change the tubing and cannula every week on Sunday night shift. Date the tubing when changed. -clean the exterior of the concentrator once a week on Sunday night shift.…

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 it was determined the facility failed to ensure residents received pain medication as ordered for 1 of 1 sampled resident (#248) reviewed for pain. This placed residents at risk for unrelieved pain. Findings include: Resident 248 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (abnormal heart beat). The 7/6/23 hospital physician orders indicated Resident 248 had chronic back pain and was to receive pregabalin (pain medication) 75 mg every eight hours. The 7/2023 MAR indicated Resident 248 did not receive pregabalin as ordered on the following occasions: -7/6/23 at 10:00 PM -7/7/23 at 6:00 AM -7/7/23 at 2:00 PM -7/7/23 at 10:00 PM Progress notes indicated the pregabalin was not available on 7/6/23 and 7/7/23. The 7/6/23 admission Summary and admission Evaluation indicated the following: -Resident 248 stated her/his lower legs were on fire; -Resident 248 had a lot of pain and to make sure pain regimen is on schedule; -Resident 248 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.

Based on observation, interview and record review it was determined the facility failed to provide appropriate pre and post dialysis assessments and accurate documentation for 2 of 2 sampled resident (#s 30 and 58) reviewed for dialysis. This placed residents at risk for lack of dialysis assessments and complications. Findings include: 1. Resident 30 was re-admitted to the facility in 2023 with diagnoses including end-stage renal disease. Resident 30's 7/18/23 Quarterly MDS BIMS score indicated the resident was cognitively intact. Resident 30's 7/20/23 Care Plan revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week at a clinic outside the facility. On 7/26/23 at 12:19 PM Resident 30 stated no one checked her/his new dialysis port after dialysis. Resident 30 stated she/he had a blood clot in the old dialysis site in her/his right arm and surgery was done on 7/19/23 to relocate the dialysis site to her/his neck. Resident 30 stated she/he took a piece of paper with vital signs and current weight 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.

Based on interview and record review it was determined the facility failed to ensure transportation was provided to a medical appointment for 1 of 1 sampled resident (#249) reviewed for follow up appointments. This placed residents at risk for delayed care. Findings include: Resident 249 admitted to the facility in 7/2023 with diagnoses including a cervical fracture. A 7/17/23 hospital discharge order revealed Resident 249 had a follow up orthopedic appointment scheduled on 7/20/23 at 3:45 PM. No evidence was found in the clinical record regarding transportation being scheduled for the 7/20/23 appointment. On 7/24/23 at 2:44 PM Resident 249 stated the facility did not schedule transportation for her/his orthopedic appointment on 7/20/23 due to poor communication and the appointment had to be rescheduled. On 7/27/23 at 4:11 PM Staff 4 (Agency/RN) stated she was aware of the missed appointment for Resident 249 and was not sure how the appointment was missed but possibly was overlooked when staff reviewed her/his admission orders. On 7/28/23 at 9:41 AM Staff 30 (Medical 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 it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner for 1 of 5 sampled residents (#32) reviewed for unnecessary medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 32 was admitted to the facility in 9/2019 with diagnoses including schizophrenia (serious mental disorder that affects how a person perceives and interprets reality), depression and anxiety. Pharmacy recommendations from 4/24/23, 5/22/23 and 6/26/23, revealed the following: evaluation of physician's orders to determine if Resident 32 was at the lowest effective dose for Abilify (an antipsychotic), Olanzapine (an antipsychotic), Lexapro (an antidepressant), Duloxetine (an antidepressant), Buspirone (an antianxiety medication), and Clonazepam (an antianxiety medication). Resident 32's record revealed no documentation of any physician follow-up or response to the 4/24/23, 5/22/23 and 6/26/23 pharmacy recommendations. On 7/28/23 at 11:10 AM Staff 2 (DNS) acknowledged…

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 it was determined the facility failed to complete quarterly psychotropic medication reviews for 2 of 5 sampled residents (#s 17 and 42) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: 1. Resident 17 admitted to the facility in 2023 with diagnoses including anxiety and depression. Review of the 6/8/23 physician orders indicated Resident 17 received clonazepam (antianxiety), duloxetine (antidepressant), quetiapine (antipsychotic) and melatonin. A Lifestyles form with review dates of 3/28/23, 3/29/23, 4/26/23 and 6/27/23 listed Resident 17's psychotropic medications with the diagnoses, and order date. The form indicated sleep and behaviors with no other information provided. A progress note dated 6/28/23 indicated the facility IDT team and pharmacy reviewed Resident 17's psychotropic medications and to see the Quarterly Psychotropic Medication Assessment. Review of Resident 17's medical record revealed no indication of a Quarterly Psychotropic Medication Assessment completed. On 7/27/23 at 8:56…

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 it was determined the facility failed to ensure routine dental services were provided to 1 of 1 sampled resident (#56) reviewed for dental services. This placed residents at risk for a lessened quality of life. Findings include: Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke. On 7/24/23 at 12:32 PM Resident 56 was observed missing one of her/his upper teeth on the right side of her/his mouth. Resident 56 stated her/his tooth fell out two plus weeks prior, staff were aware and supposed to get the missing tooth fixed but nothing occurred. No evidence was found in the clinical record regarding Resident 56's missing tooth or any indication dental services were initiated or a dental appointment was made. On 7/26/23 at 11:28 AM Staff 21 (CNA) stated Resident 56 was missing one of her/his upper teeth for greater than two weeks and was not sure if any staff reported the concern to Staff 16 (Social Service Director). On 7/27/23 at 10:31 AM Staff 20 (LPN) stated she was aware Resident 56 had a missing upper…

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 it was determined the facility failed to provide rehabilitation services for 1 of 1 sampled resident (#17) reviewed for rehabilitation services. This placed residents at risk for declined mobility and lack of quality of life. Findings include: Resident 17 admitted to the facility in 2023 with diagnoses including pain and fibromyalgia (widespread muscle pain). On 5/12/23 a concern was reported to the State Agency which indicated Resident 17 did not receive therapy as ordered and only received one session the following week. On 7/24/23 at 10:55 AM and 7/26/23 at 9:52 AM Resident 17 stated she/he did not receive therapy when she/he was supposed to. Resident 17 stated she/he never refused therapy and was never out of the building to miss therapy. Resident 17 stated she was never approached to make-up for the missed sessions. Review of the 5/2023 therapy notes indicated Resident 17 was to receive OT three times a week and PT two times a week. Review of therapy the Service Log Matrix indicated Resident 17 received one session of PT (one session missed)…

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 it was determined the facility failed to provide a safe environment for the storage of oxygen tanks for 1 of 2 sampled residents (#32) reviewed for respiratory care. This placed residents at risk for accidents. Findings include: Resident 32 was admitted to the facility in 9/2019 with diagnoses including COPD (chronic obstructive pulmonary disease). Multiple observations from 7/25/23 through 7/28/23 revealed empty and unsecured oxygen tanks stored inside Resident 32's doorway and right outside of Resident 32's door. On 7/28/23 at 10:21 AM Staff 19 (CNA) stated oxygen tanks were to be secured or stored in a locked closet by the nurses station. On 7/28/23 at 10:23 AM Staff 2 (DNS) provided the facility's Oxygen Administration policy revised 7/2023, which stated Oxygen tanks must be stored securely in a stand. On 7/28/23 at 11:02 AM Staff 2 was shown the unsecured oxygen tanks and Staff 2 stated oxygen tanks needed to be either secured or stored in the locked oxygen closet by the nurses station.