Austin Wellness & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 8 (Resident #9 and Resident #34) residents reviewed for activities of daily living. The facility failed to ensure Resident #9 and Resident #34's nails were trimmed and clean. This failure placed residents at risk for poor hygiene and decreased quality of life.Findings included: A record review of Resident #9's face sheet dated 5/07/2026 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of Alzheimer's disease (neurocognitive disorder), cerebral infarction (stroke), dysphagia (difficulty swallowing), weakness, unspecified lack of coordination, other reduced mobility, other lack of coordination, muscle weakness, and need for assistance with personal care. A record review of Resident #9's MDS assessment dated [DATE] reflected that he was not assessed for a BIMS score.…

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 a resident received care consistent with professional standards of practice to prevent pressure ulcers for 1 of 8 residents (Resident #97) reviewed for skin assessments. The facility failed to assess Resident #97's skin weekly, as required by the facility's policy, from December 2025 to May 2026 This failure placed residents at risk for unidentified skin issues.Findings included: A record review of Resident #97's face sheet dated 5/07/2026 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of sequelae of cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis), morbid (severe) obesity, and rhabdomyolysis (rapid breakdown of skeletal muscle). A record review of Resident #97's MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated moderately impaired cognition. A record review of Resident #97's care plan dated 5/07/2026 reflected that she had potential for pressure ulcer…

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 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 1 of 6 residents (Resident #1) reviewed for care plan revisions.The facility failed to ensure that Resident #1's care plan was comprehensive and complete, reflecting his complex active medical conditions.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #1's face sheet dated 03/20/26 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Coronary Artery Disease (Limited blood flow in the arteries of the heart) , End-Stage Renal Disease (kidney failure), Heart Failure, Hypertension, Diabetes Mellitus , Peripheral…

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 the comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans.The facility failed to ensure that Resident #1's comprehensive care plan was completed within 7 days after completion of the comprehensive assessment, completed on 02/05/26.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #1's face sheet dated 03/20/26 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Coronary Artery Disease (Limited blood flow in the arteries of the heart) , End-Stage Renal Disease (kidney failure), Heart Failure, Hypertension, Diabetes Mellitus , Peripheral Vascular Disease( blood circulation issues), Gastroesophageal Reflux Disease(acid reflux), Pneumonia, Chronic Obstructive Pulmonary…

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 a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured for 1 of 8 residents (Resident #1) reviewed for care plan. The facility failed to develop Resident #1's care plan to reflect refusals of showers and interventions which included skin assessment and reduction of risk for skin breakdown. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.Findings include: During an interview with the DON on 01/10/2026 at 10:48 a.m., she said she was trained on completing care plans. She said the residents' participation in ADLs and if they refused care, this information should go on the care plan. She said the care plan should be updated and she did not know why Resident #1's care plan was not updated. She said if something was not on the care plan it could affect the quality of care for the residents. She said the DON, ADON and the social…

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 make sure that drugs are stored properly and only authorized persons have access for 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure MC #1 was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included: During an Observation of the nurses station on 01/10/2026 at 07:39a.m., revealed MC#1 was unlocked and unattended. RN A was sitting inside the nurses station out of view of the medication cart. Another RN walked past MC #1 and went into the nurses station and did not lock MC #1. Residents were walking by the unlocked medication cart. MC #1 contained residents prescribed creams, residents prescribed drugs, over the counter medication, narcotics, and injectable antibiotics. During an interview with RN A on 01/10/2026 at 07:43a.m., revealed that she had been trained on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for one (1) (Resident #1) of six (6) residents reviewed for abuse and neglect.The facility failed to thoroughly investigate an alleged abuse incident reported by Resident #1 on 09/15/2025. The facility did not notify law enforcement.This deficient practice placed all residents at risk of harm from abuse due to not having a thorough investigation done for an alleged abuse.Findings Include: Record review of Resident #1's face sheet, dated 09/16/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Major Depressive Disorder ( is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with…

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 interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of three residents reviewed for care plan. The facility failed to develop Resident #1's comprehensive care plan to address all Resident #1's care needs. Resident #1's comprehensive care plan did not address the need for pain medication / management, risks for pressure ulcer development, assistance needed for ADL care, incontinence to bowel and bladder, medications Resident #1 was taking to manage disease processes, Hospice care, reason for oxygen therapy, DNR status, fall risk, elopement risks. This deficient practice could place residents at risk for not receiving necessary care and services. Findings included:Review of Resident #1's face sheet printed [DATE] reflected a [AGE] year-old male who was admitted on [DATE]and readmission of [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 3 or 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control.1. CNA A failed to change gloves when providing incontinent care to Resident #1 on 08/07/25.2. CNA B failed to conduct hand hygiene between glove changes and wiped from back to front while providing incontinent care to Resident #2 on 08/07/25.3. LVN C failed to change gloves after touching a soiled brief and before applying a clean brief to Resident #3 on 08/07/25.Thes failures could place incontinent residents at risk for infection.The findings included:1. Review of Resident #1's face sheet, dated 08/07/25, reflected an [AGE] year-old female admitted to the facility 05/14/24. Her diagnoses included cerebrovascular disease (a group of conditions that affect 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 provide a safe, functional, sanitary, and comfortable environment for 3 of 4 residents (Resident #1, Resident #2, Resident #3). The facility failed to ensure the environment was clean, sanitary and homelike for 3 of 4 residents (Resident #1, Resident #2, Resident #3) reviewed for environment, in that:. 1. There was a strong smell of urine throughout the facility. These failures could place residents at risk for not living in a comfortable and homelike environment, affecting their rights. Findings include: On 05/05/2025 beginning at 10:00AM an observation was conducted of the facility that revealed a strong urine odor in the front of the building and throughout the halls of the facility. Record review of Resident #3's face sheet indicated that Resident #3 is a [AGE] year-old woman who was admitted to the facility on [DATE]. Resident #3 has a diagnosis of Hepatitis A without Hepatic Coma (viral hepatitis that does not result in a coma) ,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 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 7 of 12 (Resident # 4, Resident #27, Resident #41, Resident # 48, Resident # 66, Resident # 76 and Resident #186) residents reviewed for resident rights. 1. The facility failed to promote Resident # 4, Resident #27, Resident #41, Resident # 48, Resident # 66, and Resident # 76's dignity while dining when staff did not complete serving meals to one table at a time before moving to the next table to serve meals without finishing serving meals at the prior table. 2. The facility failed to promote Resident # 186's dignity when staff delivered her lunch meal and left the meal on the tray without setting it up or removing delivery tray. These failures put residents at risk…

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 all residents had the right to request, refuse, and/or discontinue treatment to participate in or refuse to participate in experimental research, and to formulate an advance directive for 5 of 30 residents (Residents #22, #81, #235, and #40) reviewed for advanced directives. 1. The facility failed to ensure Resident # 22's admission face sheet included an accurate advanced directive, as it listed both Full Code and a DNR (Do Not Resuscitate) on file. Resident # 22's care plan included documentation of the DNR on file. 2. The facility failed to ensure Resident # 81 had documentation on file in their records concerning their wishes on their advance directive status. 3. The facility failed to ensure Resident # 235 had documentation of their advanced directive on the admission face sheet, although the care plan included documentation wishing to be a Full Code. No Full Code documentation in Resident # 235 records. 4. The facility failed to ensure…

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 received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally for 3 (Resident # 10, Resident # 35, and Resident # 42) of 10 residents reviewed for food preferences and for 1(Lunch on 3/4/25) of 5 meals observed in that: 1. The test tray of the lunch meal on 03/04/25 was unappetizing in appearance (no seasoning observed, and the pureed food items had all run together) a. the rolled silverware for the regular texture tray napkin was wet and soggy b. the pureed carrots for the pureed texture tray tasted only of very tart orange juice c. the pureed dinner roll tasted very doughy and underdone. 2. The facility failed to obtain food preferences for 3 residents (Resident # 10, Resident # 35, and Resident # 42). This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished…

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 food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure DS J properly used proper hand hygiene during food preparation. 2. The facility failed to ensure DS L and DS H wore a beard guard while in kitchen. 3. The facility failed to ensure all foods were labeled and dated in the kitchen. 4. The facility failed to ensure all items were covered and stored properly in the kitchen. 5. The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the inside of the microwave, ensuring staff utilize hair restraints while in kitchen, ensuring trash receptacles in kitchen had lids secured covering contents, proper storage of ice scoop, ensuring cleaning schedules and logs were being utilized, ensuring hand sinks had paper towels, These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: Observation on 3/3/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and 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 for 5 of 8 staff reviewed for infection control. 1. The facility failed to ensure CNA A conducted hand hygiene when passing resident lunch trays . 2. The facility failed to ensure MA L sanitized the blood pressure cuff after checking a resident's blood pressure . 3. The facility failed to ensure CNA D, LVN B, and the AD conducted hand hygiene between residents during lunch tray pass . These failures could place residents at risk of transmission of disease and infection. Findings include: 1. Record review of Resident #49's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included epilepsy (a group of non-communicable neurological disorders characterized by recurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 7 residents (Residents #38) reviewed for resident rights in that: The facility failed to ensure Residents #38 had a call device within reach from 3/3/25-3/6/25. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident # 38's admission face sheet dated 3/4/25 reflected a [AGE] year-old male admitted on [DATE]. Resident # 38 had diagnoses of cerebral infarction (stroke), hypertension(elevated blood pressure), traumatic subdural hemorrhage (bleeding in the brain), quadriplegia(paralysis that affects all 4 limbs), dysphagia(swallowing disorder), cognitive communication disorder (difficulties in communicating), type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar…

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 baseline care within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 10 residents (Resident #185, and Resident #135) reviewed for baseline care plans. The facility failed to ensure baseline care plans were completed for Resident #185 and Resident #135. The facility failed to develop a baseline care plan that reflected the need for Resident #185's wandering and agitation for Resident #185 The facility failed to develop a baseline care plan that reflected the individuals needs of Resident #135. This failure puts all residents at risk of not getting their needs met. Findings included: 1. review of Resident #185's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with pertinent diagnoses of depression, unspecified dementia (degenerative brain disease causing memory loss), 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 observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 8 residents (Residents #31, and #38) reviewed for activities. The facility failed to provide Residents #31 and #38 with individual or group activities. This failure could place residents at risk for a decline in their physical, mental, and psychosocial well-being. Findings include: 1. Record review of Resident #31's face sheet, dated 10/01/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included Spastic Diplegic Cerebral Palsy (both of the legs have abnormal stiffness), Dysphagia (difficulty swallowing), Aneurysm (abnormal bulge…

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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one of eight residents (Resident #37) reviewed for nutrition status maintenance. 1. The facility failed to obtain consistent weights for Resident #37. These failures could place residents at risk of further weight loss, malnutrition, and a decreased quality of life. Record review of the dietitian's orders, dated 01/22/25, stated resident was on house supplement with meals. Recommended 1:1 assistance with meals. Record review of physician's notes from a visit, dated 12/31/24, reflected Resident #37 was on a mechanical soft with chopped meat texture, thin liquids. Refer to RD for evaluation and treat for weight loss recommendations. Observation and interview with Resident #37 on 03/03/25 at 2:45 PM revealed the resident in bed watching TV. She stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Resident #186 and Resident #32) reviewed for pharmaceutical services. The facility failed to document controlled medications from the medication cart on the narcotic count sheets for Resident #186 and Resident #32. This failure could place residents at risk to medication errors . Findings include: 1. Record review of Resident #186's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction (weakness and loss of strength in upper and lower limbs), diabetes mellitus type 2, hypertension (high blood pressure), dementia (memory problem), hyperlipidemia (elevated lipids circulating in the blood), bipolar disorder (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 observations, interviews, and record review, the facility failed to establish and 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 infection for 4 of 6 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for infection control. The facility failed to wear PPE when providing high contact resident care (dressing, bathing, transfers, wound care, device) to Resident #1, #2, #3 and #4. The facility failed to have signage on resident doors that reflected PPE was required for high contact care for Resident #1, #2, #3 and #4. The facility failed to educate staff on infection control procedures related to Enhanced Barrier Precautions (EBP). These failures could place residents at risk for infection, hospitalization, or death. Findings included: Review of Resident #1's face sheet printed on 01/30/25 reflected a [AGE] year-old male admitted 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 interviews and record review, the facility failed to designate an Infection Preventionist that was qualified by education, training, experience, or certification, and who completed specialized training in infection prevention and control, for one of one facility. The facility did not designate a qualified Infection Control Preventionist. This failure could place residents at risk for cross contamination and infection. Findings included: During an interview on 01/30/25 at 1:38 PM the ADON stated she was in charge of infection control but did not have the certificate to be the infection control preventionist. The ADON stated the Administrator and the DON had certification for infection control preventionist. The ADON stated she was working on her certification of being the Infection Control Preventionist . During an interview on 01/30/25 at 2:27 pm, the ADM stated the ADON was the designated staff as Infection Control Preventionist. The Administrator stated he had certification to be infection control preventionist but has never done anything in the facility regarding…

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 provide the necessary services to maintain grooming and personal care for one of seven residents (Resident #1) reviewed for ADL care in that: The facility failed to provide residents with care and services related to activities of daily living, Resident #1 had long and dirty fingernails. This deficient practice could affect residents who were dependent on assistance with ADL's and could result in poor care and risk for skin breakdown and feelings of poor self-esteem, lack of dignity and health. Findings included: Review of Resident #1's face sheet dated 11/15/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Myalgia (pain or tenderness in one or more muscles which con involve any area of the body) unspecified site, pain in right knee, pain in left knee. Review of Resident #1's care plan initiated 05/30/2024 reflected Resident #1 had an ADLs self-care performance deficit had impaired cognitive…

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 to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for three (Residents #1, #2 and #3) of seven residents reviewed for baseline care plans. The facility failed to develop baseline care plans for Resident #1, #2, and #3. This deficient practice could place residents at risk of not having individualized needs met, a delay in services, sustaining injuries, and not receiving adequate care. Findings included: Resident #1 Review of Resident #1's admission record, dated 09/27/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury), cocaine abuse with cocaine-induced anxiety disorder, chronic viral hepatitis C (an…

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 interviews and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of seven residents reviewed for medication administration. The facility failed to ensure Resident #1 was administered her prescribed Ertapenem Sodium Injection Solution (used to treat certain serious infections). This deficient practice could place residents at risk of not being provided their routine and emergency drugs and biologicals to meet their needs, infection, or having medical conditions worsen or be exacerbated. Findings included: Review of Resident #1's admission record, dated 09/27/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury). Review of Resident #1's BIMS assessment, dated 09/25/24, reflected she had an 8 BIMS score, which indicated she had moderate…

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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of five residents reviewed for quality of care. The facility failed to conduct a fall/skin assessment or conduct neuros consistently after unwitnessed falls for Residents #1 and #2. These deficient practices could place residents at risk of harm, injuries, or hospitalization. Findings included: Resident #1 Review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including COPD (a chronic lung disease), morbid obesity, TBI, and a risk of falling. Review of Resident #1's quarterly MDS assessment, dated 07/17/24, reflected a BIMS of 8, indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she had not experienced any…

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 that medical records were accurately documented for one (Resident #3) of five residents reviewed for accurate medical records. The facility failed to ensure Resident #3's medical chart contained any documented nursing progress notes. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #3's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that causes memory loss), hypertension (high blood pressure), seizures, and type II diabetes. Review of Resident #3's quarterly MDS assessment, dated 08/15/24, reflected a BIMS of 6, indicating a severe cognitive impairment. Review of Resident #3's quarterly care plan, dated 05/30/24, reflected she had an ADL self-care performance deficit with an intervention of requiring staff supervision with transfers and bed mobility. It further reflected she…

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 TX00507691 Census of 100 Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR level II determination for 1 of 1 resident reviewed for PASRR. The facility failed to ensure Resident #1 was referred for Specialized ST, OT and PT evaluations and services after these were agreed upon during his IDT by the due date of 05/10/2024. This failure could place residents at risk of decline in functional ADLs. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included symptomatic epilepsy and epileptic syndromes with complex partial seizures (seizure disorder affecting vision and movements), quadriplegia (paralysis of all four limbs), chronic kidney disease, generalized muscle weakness, cognitive communication deficit, cerebral palsy (A congenital disorder of movement, muscle tone, or posture) and other specified sepsis (A life-threatening complication of an…

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 provide a safe, clean, comfortable, and homelike environment for four (Resident #2, Resident #4, Resident #5, and Resident #6) of thirteen residents in that: The facility failed to ensure the main dining room and resident community television area by nurses' station 2 maintained a temperature range of 71 to 81°F for Residents #2, Resident #4, Resident #5, and Resident #6. The failure could place residents at risk of illness due to heat and decreased quality of life. Findings included: Weather Underground (www.wunderground.com) revealed temperatures in [NAME], Texas for 06/24/2024 revealed a low temperature of 74 degrees Fahrenheit, a high temperature of 95 degrees Fahrenheit, and an average temperature of 84.67 degrees Fahrenheit. Observation 06/24/2024 at 11:32 am revealed two rented cooling units located in the facility main dining room that both displayed temperature screens that revealed temperatures of 87 degrees Fahrenheit.…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of three (Resident #1 and Resident #2, and Resident #3) of ten residents reviewed for medication administration, in that: The facility failed to label multi-dose, insulin medications according to recommendations and professional standards of practice in one of four medication carts reviewed for medication storage for Residents #1, Resident #2, and Resident #3. This deficient practice placed residents at risk for administration of expired medications and decreased therapeutic effects of administered medications. Findings included: Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs because of disrupted blood flow to the brain due to problems…

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 interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for 5 (Residents #1, #2, #3, #4, and #5) of 6 residents reviewed for care plans, in that: Residents #1, #2, #3, #4, and #5's comprehensive care plans were not reviewed and revised after their quarterly MDS assessments were completed. These deficient practices could place residents at risk of current needs not being met. Findings included: Record review of Resident #1's admission Record, dated 05/21/24, revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses, which included: unspecified atherosclerosis (The build-up of fats, cholesterol, and other substances in and on the artery walls), unspecified severe protein-calorie malnutrition, morbid (severe) obesity due to excess calories, dementia (A group of thinking and social symptoms that interferes…

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 incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 3 residents (Resident #1) reviewed for PASRR. The facility failed to ensure Resident #1 was referred for Specialized OT and PT evaluations and services after these were agreed upon during his IDT meeting on 12/11/23. This failure placed Resident #1 at risk of decline in functional ADLs. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included spina bifida (birth defect that occurs when the spine and the spinal cord do not develop completely), abnormal posture, lack of coordination, unsteadiness on feet, malaise (feeling uncomfortable, ill or lack of energy but you cannot explain the cause), need for assistance with personal care, muscle, weakness, mild cognitive…

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 a resident who was unable to conduct activities of daily living independently, received the necessary services to maintain good grooming and personal hygiene for 2 of 4 residents reviewed for quality of life (Resident #3 and Resident #4). 1. The facility failed to provide scheduled bath/showers for Resident #3. 2. The facility failed to provide scheduled bath/showers for Resident #4. These failures could place residents who required assistance from staff for ADL's at risk of poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Review of Resident #3's face sheet, dated 04/07/2024, reflected a [AGE] year-old female initially admitted on [DATE] with re-admission date of 2/15/24 after a three-day hospitalization, diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain), epilepsy (brain disorder causing seizures).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to prepare food in a form to meet individual needs for 1 of 4 (Resident #5) residents observed for dietary needs. The facility failed to provide a mechanical soft diet with pureed meats for Resident #5 and served her chopped meat during lunch and an entire pureed meal for dinner. This failure could contribute to causing a resident to choke and poor food intake. Findings included: Review of Resident #5's face sheet dated 04/06/2024, revealed Resident #5 was a [AGE] year-old female admitted to the facility 07/28/2021 with diagnoses that included: dementia (disorder that causes impairments in thinking, memory and behavior), major depressive disorder, dysphagia (difficulty or discomfort in swallowing), and pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit. Review of Resident #5's MDS Assessment updated 11/03/2023, revealed a BIMS score of eight indicating moderately impaired cognitive function. Resident #5 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 observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #1, 2 and 3) of 4 residents and 1 of 1 hallway observed for a clean environment. 1. The facility failed to ensure Resident #1, #2, and #3's bedroom floor was clean. 2. The facility failed to ensure the hallway floor was clean and had no foul odors. This deficient practices could place residents at risk of a decreased quality of life. Findings included: During an interview on 02/21/24 at 8:40 a.m., the ADM revealed housekeepers followed the deep clean schedule. The ADM explained housekeepers deep cleaned twice a week and spot checked and cleaned residents' rooms and commonly shared areas daily. The ADM also revealed there were two housekeepers for each shift. An observation on 02/21/24 at 10:38 a.m. revealed Resident #1's bedroom floor was sticky. During an interview on 02/21/24 at 10:47 a.m., Resident #1 revealed she cleaned her own room. Resident #1 explained the floor was sticky because housekeeping did not mop it. During an…

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 include effective communications as mandatory training for 13 of 16 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, FSS, Act Dir, RN P, LVN Q, and LVN S.) The facility failed to provided CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, FSS, Act Dir, RN P, LVN Q, and LVN S with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA F's personnel record had a hire date of 08/23/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA G's personnel record had a hire date of 02/12/20, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA H's personnel record had a hire date of 03/19/20, with annual training in-services provided by the facility that did not include evidence of effective…

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 provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 6 of 16 employees (CNA G, CNA J, LVN N, RN P, LVN Q and LVN S) reviewed for training, in that: The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA G, CNA J, LVN N, RN P, LVN Q and LVN S. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings included: Review of CNA G's personnel record had a hire date of 02/12/20, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA J's personnel record had a hire date of 08/20/21, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident…

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 Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 16 of 21 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S. This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately trained staff and could result in a decline in health and well-being. The findings were: Review of CNA F's personnel record had a hire date of 08/23/21 revealed no evidence of QAPI topics within the previous 12 months. Review of CNA G's personnel record had a hire date of 02/12/20 revealed no evidence of QAPI topics within the previous 12 months. Review of CNA H'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.

Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 7 of 16 staff (CNA G, CNA J, LVN N, RN P, LVN Q, LVN R and LVN S) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to CNA G, CNA J, LVN N, RN P, LVN Q, LVN R and LVN S. This failure could place residents at risk of illness due to lack of staff training. The findings were: Review of CNA G's personnel record had a hire date of 02/12/20, revealed no evidence of infection control topics within the previous 12 months. Review of CNA J's personnel record had a hire date of 08/20/21, revealed no evidence of infection control topics within the previous 12 months. Review of LVN N's personnel record had a hire date of 12/07/98 revealed no evidence of infection control topics within the previous 12 months. Review of RN P's personnel record had a hire date of 12/22/22, revealed no evidence of infection control topics within the previous 12 months.…

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 communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for for 16 of 21 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that: The facility failed to ensure that compliance and ethics training was provided to CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of CNA F's personnel record had a hire date of 08/23/21 did not include evidence of communication related to the compliance and ethics program's standards. Review of CNA G's personnel record had a hire date of 02/12/20 did not include evidence of communication related to the compliance and ethics program's standards. Review of CNA H's personnel record had a hire date 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, the facility failed to provide mandatory effective behavioral health training for 8 of 16 employees (CNA F, CNA G, CNA J, LVN N, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to CNA F, CNA G, CNA J, LVN N, RN P, LVN Q, LVN R, and LVN S. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings included: Review of CNA F's personnel record had a hire date of 08/23/21 revealed no evidence of behavioral health training. Review of CNA G's personnel record had a hire date of 02/12/20 revealed no evidence of behavioral health training. Review of CNA J's personnel record had a hire date of 08/20/21, revealed no evidence of behavioral health training. Review of LVN N's personnel record had a hire date of 12/07/98 revealed no evidence of behavioral health training. Review of RN P's personnel record had a hire date of 12/22/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs for 1 of 13 (Resident #81) residents reviewed for call lights on the 2100 hall in that: The facility failed to ensure Residents #81's call light was within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed and risk of falling. The Findings Included: Record review of Resident #81's face sheet, dated 9/6/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), depression (mood disorder), cerebral vascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply blood), bilateral occlusion and stenosis of carotid arteries (blockage of arteries that are on both sides of the next that carry blood to the brain), contractures of left shoulder, left wrist and left hand (a condition…

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 that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #81) reviewed for comprehensive care plans in that: Resident #81's comprehensive care plan did not address the resident's Hospice services. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Record review of Resident #81's face sheet, dated 9/6/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), depression (mood disorder), cerebral vascular disease (occurs as a result of disrupted blood flow…

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 residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 1 residents (Resident # 249) reviewed for oxygen in that: Resident #249's oxygen tubing were not changed as ordered. This deficient practice could affect residents in the facility ordered to receive oxygen therapy as needed and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. The findings were: Record review of Resident #249 's face sheet, dated 01/12/024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to: Malignant Neoplasm of Prostate (cancer or the prostate), chronic pain, major depressive disorder (more often than not persistent feeling of sadness and loss of interest in activities-interferes with daily life), and Dyspnea (shortness of breath, difficult or labored breathing).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure nurse aides can demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments and described in the plan of care for 1 of 3 residents (#82) in that: 1. The facility failed to ensure CNA A cleaned Resident #82's penis by changing wet wipes or folding the wet wipe to change surfaces. 2. The facility failed to ensure CNA T cleaned Resident #82's using 1 wipe and moving the wet wipe back and forth at the coccyx area without changing surfaces. These deficient practices affect residents who require peri care and could result in infection. The findings included: Record review of Resident #82's face sheet dated 01/12/2024 revealed the [AGE] year-old male resident was admitted initially 03/01/2023. Resident #82's diagnoses included unstable angina, pressure ulcer on sacral region, stage 2 (skin is broken, leaves an open wound, or looks like a pus-filled blister),…

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 drugs and biologicals were stored in accordance with currently accepted professional principles, for 2 of 3 medication carts observed, in that: 1. The Middle Medication Cart 2200 hall contained eighteen loose medication pills. 2. The Hall Back Medication Cart 2200 hall contained eight loose medication pills. These practices could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. The findings included: 1. Observation on 01/10/2024 at 9:10 a.m. of the 2200 Hall Middle Medication Cart revealed there were eighteen loose medication pills inside one of the drawers of the cart. During an interview with Nurse T on 01/10/2024 at 9:12 a.m., Nurse T confirmed there were eighteen loose medication pills inside a drawer of the Middle Medication Cart. 2. Observation on 01/10/2024 at 9:34 a.m. of the 2200 Hall Back Medication Cart revealed there were eight loose medication pills inside one of the drawers of the cart. During an interview with Nurse U 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, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. A metal pan covered with white wax style paper covering approximately 6 chicken breasts was placed on a shelf in the bottom of the walk-in cooler, the chicken was removed from the manufacturer's box and was not completely covered or in an enclosed container. 2. Six loaves of raisin bread with no dates or labeling of any type on the individual loaves and when the raisin bread was removed from the original manufacturer's box, placed on a metal tray with the date it was taken out of the freezer by the Food Service Supervisor. These failures could place residents at risk for food-born illness, and food contamination. Findings included: Observation on 05/09/2023 at 8:45 a.m. in the dry storage room revealed: 1. Approximately 6 partially chicken breasts in a metal pan partially covered, allowing air to reach the chicken breasts. 2. Six loaves of raisin…

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 dispose of garbage and refuse properly, for 2 of 2 facility dumpsters in that: 1. Dumpster #1 had the side door open making trash placed in the dumpster visible for 3 of 3 observations. 2. Dumpster #2 had the top lid open making trash placed in the dumpster visible. These deficient practices could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents, and expose them to germs and diseases carried by vermin and rodents. The findings were: Observation on 01/10/2024 beginning at 1:14 p.m. revealed dumpster #1 with the side door open making the trash placed in the dumpster visible. Observation revealed dumpster #2 with one side of the top lid open making trash placed in the dumpster visible. Observation on 1/10/24 beginning at 5:25 p.m. revealed dumpster #1 with the side door open making the trash placed in the dumpster visible. Observation revealed dumpster #2 with both sides of the top lid open making trash placed in the dumpster…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 1 resident (Resident # 7) reviewed for hospice services in that: The facility failed to maintain required hospice forms and documentation to ensure residents received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Review of Resident #7's face sheet dated 01/22/2024 revealed a [AGE] year-old resident originally admitted on [DATE] and initially admitted on [DATE] with diagnoses that included but not limited 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 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 to help prevent the development and transmission of infections for 3 of 3 staff (CNA A, CNA T and LVN S) reviewed for infection control, in that: 1. CNA A, while providing peri-care to a male resident, did not change her gloves during the whole procedure. 2. CNA T, while providing peri-care to a male resident, did not sanitize her hands between glove changes. 3. LVN S, while looking at a catheter bag that was hanging from the bed side bottom bed frame and partially touching the floor, did not use gloves while handling the catheter bag and touched the tubing on Resident #7's bed without practicing hand hygiene. These deficient practices could place residents at-risk for infections. The findings included: 1. and 2. During an observation on 01/11/2024 at 11:27 a.m. with CNA A and CNA T providing incontinent/peri care to Resident #82. CNA T asked CNA A if she felt comfortable providing…

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 provide resident abuse prevention training to 2 of 21 staff reviewed including CNA G and LVN Q. The facility failed to ensure that 2 of 21 staff reviewed had completed their mandatory abuse annual training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Record review of the annual training information provided by the HR Personnel revealed that CNA G (hired-02/12/20) and LVN Q (hired-03/15/21) had not completed their mandatory abuse annual training. During an interview with the Administrator on 01/12/24 at 5:30 pm, the Administrator stated they provided abuse prevention training as required but she was not aware that the identified staff members had not completed the training.