Georgia Manor Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 (Resident #3, Resident #13, Resident #41, and Resident #43) of 12 residents reviewed for respiratory care. 1. The facility failed to ensure Resident #3 received O2 via NC at the rate of 2 l/m as ordered by her physician. 2. The facility failed to ensure Resident #13 received O2 via NC at the rate of 2 l/m as ordered by her physician. 3. The facility failed to ensure Resident #41 received O2 via NC at the rate of 5 l/m as ordered by his physician. 4. The facility failed to ensure Resident #43 received O2 via NC at the rate of 4 l/m as ordered by hi physician. These failures could place residents who receive oxygen at an increased risk of hypercapnia (too much carbon dioxide…

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 store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food safety. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could place residents at risk of food borne illnesses. Findings include: Observation of the kitchen food prep activities on 4/15/25 from 11:15 a.m. to 12:15 p.m. revealed the following: At 12:00 p.m., [NAME] B was observed in the kitchen serving the noon meal. [NAME] B changed her gloves, picked up plates and set them on the serving line, took lids off food, touched the plates, picked up a knife and laid the knife on the serving line. [NAME] B picked up a plate and plated one piece of chicken. [NAME] B put the plate down and picked up the knife with her gloved hands. [NAME] B then placed her right hand over the chicken piece and began slicing the chicken into strips on the plate. [NAME] B then rearranged the chicken on the plate with her gloved hands. [NAME] B put the knife down and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #43) of 12 residents reviewed for PASRR. The facility failed to refer Resident #43 for a level II PASRR upon receipt of a bipolar diagnosis. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Included: Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder current episode depressed moderate (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) dated 02/28/25 and listed as her primary diagnosis. Record review of Resident #43's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #13 and Resident #43) of 12 residents reviewed for comprehensive care plans. 1. The facility failed to include Resident #13's diagnosis of PTSD in her care plan. 2. The facility failed to remove anticoagulant medication from Resident #43's care plan and to include in her care plan her bipolar disorder diagnosis and the fact that she was receiving anticonvulsant medication. These failures could lead to residents not receiving needed care and/or consideration from staff as care is provided and/or receiving improper care/treatment. Findings Included: 1. Record review of Resident #13's admission record dated 04/15/25 revealed an [AGE] year-old female…

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 that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one of one oxygen tanks observed during the lunch meal. -an unsecured oxygen bottle was observed in the dining room during the lunch meal with 16 residents and 10 staff present. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, and feeling of isolation. Findings include: During an observation on 04/15/25 at 12:08 PM 16 resident and 10 staff were present in the dining room. Noted in the dining room by the exit door to the patio was a freestanding oxygen bottle that was unsecured. During an observation on 04/15/25 at 12:14 PM the HRD moved the unsecured oxygen tank to the back of the closest resident's chair and placed the oxygen tank in an oxygen tank holder. During an interview on 04/16/25 at 01:03 PM the HRD who reported…

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 that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #2 and Resident #5) of 6 residents reviewed for reporting of abuse, neglect, exploitation or mistreatment. The facility failed to report to the state within 2 hours when Resident #5 hit Resident #2. This failure could place residents at risk of continued abuse. Findings Included: Record review of Resident #2's admission record dated 06/27/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not…

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, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident # 1) of 6 residents reviewed for quality of care. The facility failed to enter physician's orders in the EHR which resulted in Resident #1 missing an appointment on 05/21/24 to have an ILR placed. This failure could place residents at risk of not receiving necessary care and/or treatment. Findings Included: Record review of Resident' #1's admission record dated 06/27/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), acute respiratory failure with hypoxia…

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, in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for one (Resident #4) of 6 residents reviewed for accuracy of records. The facility failed to document the administration of pain medication on 05/30/24 to Resident #4. This failure could place residents at risk of receiving medications in doses other than those ordered. Findings Included: Record review of Resident #4's admission record dated 06/27/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acquired absence of unspecified leg above knee, polyneuropathy (malfunction of many peripheral nerves throughout the body), and atherosclerosis of native arteries of extremities (fats, cholesterols, and other substances collected on the inner walls the arteries) with rest…

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 that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the residents to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 5 residents reviewed for abuse/neglect. The facility failed to report an injury of staff inflicted injury (fingernail wound marks to Resident #1's right hand) on 4/16/24 to the Administrator and to the state within 24 hours. This failure could place residents at risk of not having incidents of possible abuse and neglect reviewed and investigated in a timely manner…

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 drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 2 medication carts reviewed for medication storage. -70 medications were found left loose in the B & C Hall medication cart and 4 medications were found left loose in the A Hall medication cart. -2 insulin medications were found in Hall B & C medication cart with no date of when they were opened. The facility's failure to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable could place 40 residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. Findings include:…

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 infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -RN B failed to perform hand hygiene (HH) before donning gloves to administer an inhalation medication. -RN B failed to perform HH and don gloves before performing a glucose check. -LVN F failed to perform HH before or after administering an injectable medication. -LVN F failed to don or doff gloves before or after administering an injectable medication. -CNA C failed to perform HH or glove change after performing incontinent care on a resident and starting with the clean aspect of incontinent care. -CNA E failed to perform HH or glove change during incontinent care of resident. -CNA E failed to perform incontinent care on a resident in an aseptic manner. -CNA C failed to perform HH before donning new gloves after being…

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 each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for one (Resident #8) of 12 residents reviewed for rights, in that: The facility failed to ensure Resident #8 felt safe within her room environment as well as her preference for TV volume were met. This failure could place the residents at risk for a diminished quality of life, well-being, and dignity. Findings included: Record review of Resident #8's admission record dated 4/15/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE], with a more recent admission date of 02/03/2023. Resident #8 had diagnoses that included, but were not limited to, COPD (chronic obstructive pulmonary disease which refers to a group 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 12 residents (Resident #32) whose MDS assessments were reviewed. Resident #32's MDS assessment indicated in Section B that his vision was adequate, and he did not have corrective lenses. This failure to ensure accurate assessments may place resident at risk for improper or inadequate care due to staff lack of knowledge about the resident's status, needs, strengths, and areas of decline. Findings include: Record review of Resident #32's face sheet dated 4/14/24 revealed a [AGE] year-old male with an original admission date of 05/22/23 with a more recent admission date of 03/23/24. Resident #32 had diagnoses that included, but were not limited to: Pulmonary hypertension (high blood pressure that affects arteries in lungs and heart), Major depressive disorder (mental illness causing sadness due to lack of chemicals in the brain that causes happiness), generalized anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 12 residents (Resident #32) reviewed for comprehensive care plans in that: Resident #32 had a physician's order for prescription glasses that was not addressed in his care plan. This failure could place residents at risk of receiving care that is not person-centered, substandard, unable to meet their needs, or inadequate to prevent complications. The findings included: Record review of Resident #32's face sheet dated 4/14/24 revealed a [AGE] year-old male with an original admission date of 05/22/23 with a more recent admission date of 03/23/24. Resident #32 had diagnoses that included, but were not limited to: Pulmonary hypertension (high blood…

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 that one (Resident #32) of 12 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. The facility did not address Resident #32's need for prescription glasses following a physician's visit, for 6 months. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem. Findings included: Record review of Resident #32's face sheet dated 4/14/24 revealed a [AGE] year-old male with an original admission date of 05/22/23 with a more recent admission date of 03/23/24. Resident #32 had diagnoses that included, but were not limited to: Pulmonary hypertension (high blood pressure that affects arteries in lungs and heart), Major depressive disorder (mental illness causing sadness due to lack of chemicals in the brain that causes happiness), generalized anxiety…

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

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a weekfor the period reviewed from 11/1/23 to 4/13/24. The facility did not have an RN in the facility on 11/18/23 and 11/19/23, accounting for 2 days in the past months for the peroiod reviewed from 11/1/23 to 4/13/24. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care. Findings include: During an interview on 4/14/24 at 1:30 pm, the HRC stated she called the corporate office and the HRD from Corporate pulled the timecard clock in and out information for RN coverage from November 2023 to present as requested. She stated the information was the most accurate information available. Record review of the facility's last 5 months of time sheetsfrom 11/1/23 to 4/13/24 for RN coverage revealed that the facility did not have an RN in the facility on 11/18/23 and 11/19/23. During an interview on 4/15/24 at 2:20 pm, the CRN…

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 record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of each resident for 4 out of 16 residents (Residents #2, #5, #32, #38,) whose medical records were reviewed for medication administration. -The facility administered insulin to Resident #5, Resident #32, and Resident #38 after it was expired. -RN B documented administration of an injectable medication under MA D's computer access, even though MA D did not give the medication. -RN G administered an injectable medication, and RN I documented medication administration under RN I's credentials. -The facility failed to establish a procedure to ensure Resident #2's medications were her prescribed medications before leaving the facility for weekend pass, which led to Resident #2 receiving another residents Depakote while out on pass. These deficient practices 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, the interview and record review, the facility failed to ensure residents were free of any significant medication errors for one of 1 (Resident #5) residents reviewed for medication administration. -RN was attempting to administer Resident #5's expired insulin. This failure could place residents who receive insulin medications at an increased risk for complications such as increased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process. Findings include: Record review of Resident #5's face sheet revealed Resident #5 is a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's current diagnosis was as follow, but not limited to type 2 diabetes mellitus without complications, other specified abnormal findings of blood chemistry, unspecified protein-calorie malnutrition, depression, unspecified, anxiety disorder, unspecified. Record review of Resident #5's current MDS, dated [DATE] revealed that Resident has a BIMS of 14. Active…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. A. CK A did not perform hand hygiene appropriately when preparing pureed foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination. Findings included: During an observation and interview on 4/14/24 at 11:00 AM, CK A was observed preparing the mechanical soft and pureed foods. CK A changed her gloves then touched various kitchen surfaces including the prep table and the puree machine. CK A removed the lid of the puree machine and put a chicken patty into the machine with her gloved hands. CK A did not change her gloves or wash her hands. CK A then walked over to another part of the kitchen and shook the handle of the fryer basket. CK A walked back to the puree machine reached into the machine, picked up a chicken patty out of the puree machine and tore…

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 maintain complete, accurate, readily accessible, and systemically organized records for 1 (Resident #5) of 16 residents reviewed for medical records. -RN B documented administration of injectable medication under MA D's computer access. -RN G administered injectable medication, RN I documented medication administration under RN I's credentials. This failure could place residents at risk of not receiving appropriate care through inaccurate documentation which can be misleading to care providers regarding what care, medications, and treatments residents have or have not received. Finding include: Record review on 04/15/24 at 09:11 AM revealed Resident #5's MAR indicated that MA D gave Resident #5 her insulin injection on 04/14/2024 at 0700 AM. Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to facility on 07/25/2018 with, but not limited to the following diagnosis: UNSPECIFIED DEMENTIA, UNSPECIFIED…

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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for care in that: Resident #1 was left exposed in his room in an undignified manner. This failure could cause residents to feel uncomfortable and disrespected leading to feeling of isolation and deterioration in general health conditions. Findings include: Record review of Resident #1's face sheet dated 2-27-2024 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), hypertension(a condition in which the foresee of the blood against the artery walls is too high), malignant neoplasm of the bladder, (a fast-growing cancer of the bladder that spreads to other areas 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 observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. DC A failed to wear a proper hair restraints while in the kitchen. This failure could place residents at risk of food contamination. Findings include: An observation on 02/08/2024 at 9:22 AM revealed DC A was in the kitchen preparation area without a hair restraint covering short stubble on DC A's head and a beard restraint covering DC A's mustache. In an observation and interview on 2/8/24 at 11:51 AM with the DS and DC A, the DS stated DC A was required to wear a hairnet while in the kitchen. The DS called DC A over and advised he needed to put a hair net on. DC A stated he was bald. The DS advised of the mustache and he needed to cover it. The DS demonstrated how to put a hair net on facial hair. DC A stated he would wear a mask and placed a mask over his facial hair covering all facial hair. DS stated a negative outcome was hair could be in…

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, interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 (Resident #3) residents reviewed for medication administration. Resident #3 did not receive a Fentanyl transdermal (pain medicine delivered through the skin) patch every three days as ordered by her physician. The failure was identified as past non-compliance as the facility had instituted adequate corrective measures to prevent reoccurrence of the non-compliance. The facility's failure to administer medications correctly could affect all residents resulting in exacerbation of their condition resulting in complications from deterioration in health, extended recoveries, hospitalizations, and death. Findings include: Record review of Resident #3's clinical record revealed a [AGE] year old female, admitted on [DATE], with the following diagnoses: Chronic Obstructive Pulmonary Disease, chronic pain, vitamin D deficiency, type 2 Diabetes, major depressive disorder,…

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 interviews and record reviews, the facility failed to ensure compliance with Texas Health and Safety Code, Chapter 250 related to criminal history for potential employees for 2 of 5 employee records reviewed for criminal history, in that:. HK1 and HK2 were not cleared of criminal history prior to start date. This failure has the potential to affect residents in the facility by placing them at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization. Findings Included: Record review of HK1 employee file revealed a hire date of 7/31/23. Review revealed that criminal history was not obtained until after hire of HK1 on 8/1/23. Record review of HK2 HK1 employee file revealed a hire date of 7/31/23. Review revealed that criminal history was not obtained until after hire of HK2 on 8/2/23. In an interview on 9/5/23 at 2:53 PM with the ADM revealed that Human Resources position was filled by ADM prior to hire of current employee. She indicated that she is aware these records were pulled after hire due to previous Human Resources manager failing to complete…

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 store, prepare, and serve food under sanitary conditions in 1of 1 kitchen reviewed for kitchen sanitation. CNA A failed to restrain hair when entering the kitchen. These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Included: During an observation on 9/5/23 at 9:40 AM, CNA A was observed walking into the kitchen from the dining area two times without donning a hair net. During an Interview on 9/5/23 at 2:42 PM, CNA A stated that policy states a hair net is to be worn in the kitchen. CNA A agreed that she entered the kitchen without donning a hair net. CNA A confirmed she does get the handbook where the policy is stated and indicated a negative outcome could be hair in the food. During an interview 9/5/23 at 3:15 PM, DM stated that all staff are to don hair nets, masks, and gloves while in the kitchen. The DM stated it was part of the training on proper dress in the kitchen. The DM stated that a negative outcome would be cross…

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.