Coral Rehabilitation and Nursing of Austin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 6 (Resident #1) residents reviewed, in that: There was no physician order for the use of the continuous positive airway pressure machine for Resident #1. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings were: Record review of Resident #1's face sheet dated 12/4/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: chronic obstructive pulmonary disease (a lung condition that makes breathing hard due to inflamed, narrowed airways), bipolar disorder (a disorder causing extreme mood shifts), and generalized anxiety disorder (a mental health condition marked by excessive, uncontrollable worry about various everyday things). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating intact cognition. Record review 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 observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control. The facility failed to keep an effective pest control program to ensure the residents' rooms including bathrooms, halls, and recreation room (where resident activities are held) were free of roaches, flies, spiders, and water bugs. This failure could place residents at risk for reduced quality of life and poor sanitary environment.Findings included: Review of Resident #11's face sheet dated 09/10/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bacteremia (bacteria in the blood), thrombocytopenia (low platelet count), and hepatic encephalopathy (brain disfunction caused by liver disfunction). Review of Resident #11's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact.…

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 the comprehensive assessment accurately reflected the resident's status for 3 (Resident #1, Resident #17, and Resident #70) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure the MDS dated [DATE] was updated to reflect an active pressure wound for Resident #1. The facility failed to ensure the MDS dated [DATE] was updated to reflect an active pressure wound for Resident #17.The facility failed to ensure the MDS dated [DATE] was updated to reflect an active pressure wound for Resident #70. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.Findings include: Review of Resident #1's face sheet dated 09/11/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included pressure ulcer of right buttock stage 3, pressure ulcer of sacral region stage 4, unspecified protein calorie malnutrition,…

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 ensure residents who was unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 3 of 8 residents (Resident #9, Resident #18, and Resident #44) reviewed for Activities of Daily Living's. The facility failed to ensure Resident #9 and Resident #44's fingernails were trimmed. The facility failed to ensure Resident #18's facial hair was shaved. This failure was evident and could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.Findings included:Record review of Resident #9's Face Sheet dated 09/11/2025 reflected a [AGE] year-old-male admitted to the facility on [DATE] with a diagnoses that included Schizoaffective Disorder (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, and mood disorder symptoms), Bipolar (a mental health condition that causes extreme mood…

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

Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 (Medication storage room- Hall 100, Medication storage room-Hall 200) of 2 Medication storage rooms and 1 (Nurses' med cart - Hall 100) of 4 medication carts reviewed for medication storage. The facility failed to ensure :1. The medications stored in the hall 100 and hall 200 medication storage rooms were not expired .2. The content in a medication bottle in the hall 200 medication storage room was the medication labelled on the bottle.3. No mobile phone was stored in the hall 100 nurses' medication cart.4. Food items were not stored in the medication refrigerator in the hall 100 medication storage room. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.The findings included:During an observation of the facility's medication storage room in the Hall 200 on 09/09/2025 at 8:50am it 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 observation, interviews, and record reviews; the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to dispose of open stored perishable food products. 2. The facility failed to properly label and date food products in one of two freezers. 3. The facility failed to properly label and date food products in two of two kitchen pantries. 4. The facility failed to properly label and date food products throughout one of one kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.Findings include:Observation on 09/09/2025 at 10:20 AM during a walk-through of the facility kitchen revealed three large industrial facility refrigerators, two large industrial facility freezers, and two kitchen pantries. Observation revealed there was an open bag of undated and not labeled frozen dinner roll found in one of two freezers. Observation revealed…

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 a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 (Resident #18) of 8 residents reviewed for sanitary rooms. The facility failed to ensure Resident #18's floor was not sticky on 09/09/25 at 12:14 PM and 3:30 PM. This failure could place residents at risk for reduced quality of life and poor sanitary environment. Findings included:Review of Resident #18's admission Record, dated 09/09/25, reflected she was an [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, cognitive communication deficit, schizoaffective disorder, anxiety disorder, vascular dementia, and depressive disorders. Review of Resident #18's Quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated she was cognitively intact. During an observation of Resident #18's room on 09/09/25 at 12:14 PM, she was not in her room. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to 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 #33) of 5 residents reviewed for PASRR. The facility failed to perform a new PASRR level 1 assessment on Resident #33 for the diagnosis of bipolar disorder. This failure could place residents at risk of not receiving needed services and support.Findings Included:Record review of Resident #33's face sheet dated 09/10/25 revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included congestive heart failure, muscle weakness, lack of coordination, cognitive communication deficit, diabetes mellitus, presence of cardiac pacemaker, hypertension, anxiety disorder and bipolar disorder (onset date: 01/13/23). Record review of Resident #33's quarterly MDS dated [DATE] revealed a BIMS…

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 the resident's baseline Care Plan to include the minimum healthcare information necessary to properly care for a resident for 1 of 6 residents (Resident #55) whose records were reviewed for baseline care plans. The facility failed to ensure Resident #55 has a baseline care plan for the Jackson Pratt drain (a medical device used to remove excess fluid from a surgical site or wound, preventing swelling and promoting healing) and skin care at the incision site, since his admission on [DATE]. This failure could place residents at risk of not receiving required care.Findings included: Record review of Resident #55's face sheet dated 09/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included encephalopathy (disturbance in brain function), acute pancreatitis (inflammation in pancreas) with infected necrosis (tissue death), hepatic fibrosis (scar tissues in the liver), acute respiratory failure, muscle…

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 records review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 resident (Resident #55) of 5 residents reviewed for treatments. The facility failed to ensure Resident #55 received a continuous quality Jackson Pratt drain care and skin care at the incision site, since his admission on [DATE]. This failure could lead to outcomes, including pancreatic fistulas (an abnormal opening or tunnel that forms in the pancreas and allows pancreatic fluid to leak into surrounding tissues or organs), infections and hemorrhage.Findings included:Record review of Resident #55's face sheet dated 09/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included encephalopathy (disturbance in brain function), acute pancreatitis (inflammation in pancreas) with infected necrosis (tissue death), hepatic fibrosis (scar tissues in the liver), acute…

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, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #70) of 6 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure LVN I and CNA J changed dirty gloves when handling clean items and sanitized the surfaces while providing peri care and wound care to Resident #70. This failure could place residents at risk for healthcare associated cross-contamination and infections.Findings Included:Record review of Resident #70's face sheet dated 09/10/25 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hemiplegia (paralysis of one side of the body), aphasia (inability to communicate), muscle weakness, muscle wasting and atrophy, pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, 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 for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to report Resident #1's injury of unknown origin to the SSA. Staff observed Resident #1 had discoloration to his buttocks area on 09/10/25. Staff confirmed Resident #1's discoloration was an acute (sudden) femur (thigh) fracture on 09/11/25. This failure could place residents at risk of untreated medical problems, worsening injuries, mental anguish, and reduced quality of life. Findings included:Review of Resident #1's admission Record, dated 09/18/25, reflected he was an [AGE]…

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 notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and ensured the written notice included a statement of the resident's appeal rights, which included the name, address (mailing and email), and telephone number of the entity which received such requests and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request for 2 of 3 residents (Resident #2 and Resident #3) reviewed for discharge planning. 1. The facility failed to notify Resident #2 and Resident #2's RP of Resident #2's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understood, and at least 30 days before Resident #2 was discharged from the facility on 09/04/25, 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 interview and record review the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 2 of 4 residents (Resident #2, and Resident #3) reviewed for pressure ulcers.The facility failed to follow the physician's orders for providing wound care for Resident #2 and Resident #3, on a regular basis.This failure could place residents at risk of worsening their wounds. Findings Include: 1. Record review of Resident #2's face sheet, dated 09/05/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included acute congestive heart failure ( sudden and severe failure of the heart) , obesity, asthma, acute respiratory failure and edema (Swelling). Record review of Resident #2's initial MDS, dated [DATE], revealed a BIMS score of 15, which indicated his cognition was intact. Resident #2 had the risk of pressure ulcers/injuries and the recommended applications of ointments. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews 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 in one of three residents (Resident #4) review for infection control. 1. LVN E failed to perform hand hygiene before and after glove changes while performing trach care and suctioning on Resident #4. 2. LVN E failed to follow sterile technique while Suctioning Resident 42. These deficient practices could place residents at risks for infection, respiratory distress, hospitalization.Findings include:Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old male with an original admission date of 01/13/2025 and readmission date of 05/06/2025. Resident #4 had diagnoses which included tracheostomy status (a surgical procedure that creates an opening in the trachea-windpipe to allow breathing), acute 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 ensure that residents who needed respiratory care were provided with care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure Resident #1 had an order indicating an oxygen flow rate via his trach collar while on his room concentrator and portable oxygen unit as needed for hypoxia from 06/06/25 through 08/15/25. These failures could place residents at risk for symptoms and manifestations of hypoxia, the decreased perfusion of oxygen to the tissues and a decreased quality of care.Findings include: Review of Resident #1's face sheet dated 08/15/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (low levels of oxygen in body tissues), dependance on renal…

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 a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 6 residents observed for a clean environment. The facility failed to ensure Resident #1 had a homelike environment by not repairing the ceiling in his room in a timely manner. The deficient practice could place resident at risk of a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet dated 07/23/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses that included Fracture of T11-T12 Vertebra (compression fractures of small bones forming the backbone), Dependence on Renal Dialysis (the need for dialysis treatment to replace the function of the kidneys), Heart Failure (congestive heart failure, is a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's need), Embolism And Thrombosis of Deep Veins of Right Upper (a condition where 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 interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #1, Resident #4, and Resident #8) of ten residents reviewed for quality of care. The facility failed to: 1. Ensure Resident #1 had orders to manage or maintain his colostomy (an opening in the large intestine) since admission date 05/23/2025. 2. Ensure Residents #4 and #8 had a physician's order for the days they received their dialysis treatment. Residents #4 and #8 both went to dialysis on Mondays, Wednesdays, and Fridays. This deficient practice could place residents at risk of not receiving adequate care, harm, or injuries. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including spina bifida…

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 7 residents (Resident #2, 3, 4 & 5) reviewed for infection control. The facility failed to have signage on resident doors that reflected PPE was required for high contact care for Residents #2, 3, 4 and 5 on 06/05/2025. The facility failed on 06/05/2025 when staff failed to wear PPE while providing high contact resident care (dressing, bathing, transfers, wound care, device) to Residents #3 and 4. The facility failed when ADON did not change gloves or perform hand hygiene while providing wound care for Resident #4's left heel on 06/05/2025. These failures could place residents at risk for infection, hospitalization, or death. Findings included : Review of the undated face sheet for Resident #2 reflected a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #3) of 4 residents review for catheter care. The facility failed when RN A did not re-insert Resident #3's foley catheter (a medical device that helps drain urine from the bladder) when it came out on 06/05/2025 sometime around 7:00 am until 3:25 pm. Resident #3 voiced multiple times how she would prefer her catheter to be in because she could not tell when she was voiding on herself which made her uncomfortable. This deficient practice could place residents at risk for infection, sepsis (is a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death.) and hospitalization. Findings included: Review of the undated face sheet for Resident #3 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included…

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 7 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8) of 7 residents reviewed for a clean and homelike environment. 1. The facility failed to maintain temperatures between 71 degrees and 81 degrees Fahrenheit on the 100 and 200 halls on 05/20/2025. This failure could place residents at risk of living in an uncomfortable and unsafe environment, diminished quality of life and experience symptoms related to heat exacerbation. Findings include: Review of Resident #2's face sheet reflected at [AGE] year-old woman admitted on [DATE] with diagnoses of primary osteoarthritis right shoulder (condition where connection arm bone and should brake joint break down over time), malignant neoplasm of brain (cancerous brain tumor), central pain syndrome (neurological condition caused by long-term pain) and generalized anxiety disorder (mental health…

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 that all allegations involving abuse, neglect, and misappropriation were reported immediately to the State Survey Agency (HHSC), but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, for 2 of 5 residents (Resident #3 and Resident #4) reviewed for abuse. The facility failed to report to the State Survey Agency (HHSC) an incident of alleged abuse/neglect when Resident #4 grabbed Resident #3's walker and pushed it causing Resident #3 to fall and sustain a large skin tear on his forearm on 04/05/25. This failure could place residents at risk for harm to include physical abuse, a diminished quality of life, and psychosocial harm. Th e findings included: A review of Resident #3's face sheet, printed on 05/09/25, reflected a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE]. His diagnoses included thrombocytopenia (a blood disorder that can lead to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #1) of 4 residents reviewed for physician notification, in that: The facility failed to notify Resident #1's physician or nurse practice of missed medications due to the resident being out on pass from the facility on 04/01/2025, 04/02/2025, 04/03/2025, 04/05/2025, 04/06/2025 04/07/2025 and 04/08/2025. This failure could result in decreased continuity of care, and a delay in needed treatment and services. Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old woman admitted on [DATE] with diagnoses of apraxia (disorder that disrupts the brains' ability to plan and sequence motor movements), atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the walls in the heart), cerebral aneurysm (bulge or ballooning in a weakened area of a blood vessel in the brain), paranoid…

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 provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for 1 of 4 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's aspirin, doxepin, divalproex, haloperidol, folic acid, multivitamin and metoprolol were administered according to the physician's orders. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life. Findings include: Review of Resident #1's face sheet reflected a [AGE] year-old woman admitted on [DATE] with diagnoses of apraxia (disorder that disrupts the brains' ability to plan and sequence motor movements), atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the walls in the heart),…

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 promptly to assist residents in obtaining routine dental services to meet the needs of 3 (Resident #2, Resident #3, and Resident #4) of 4 residents reviewed for dental services. 1. The facility failed to provide or obtain dental services for Resident #2, Resident #3, and Resident #4. 2. The facility failed to promptly provide dental services for Resident #3 due for denture placement and document why the referral did not occur within three days. This failure could place residents at risk of oral complications, pain, difficulty eating and diminished quality of life. Findings included: 1. Review of Resident #2's face sheet reflected a [AGE] year-old woman re-admitted on [DATE] with diagnoses of malignant neoplasm of brain (brain cancer), central pain syndrome (chronic pain due to damaged or dysfunction of brain or spinal cord), dysphagia (difficulty swallowing), generalized anxiety disorder (mental condition that causes persistent and excessive worry),…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified for one (Resident #1) of four residents reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect her falls on 02/11/2025, 03/09/2025 and 03/23/2025. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings include: Review of Resident #1 face sheet reflected a [AGE] year-old woman admitted on [DATE] with diagnoses of apraxia (disorder that disrupts the brains' ability to plan and sequence motor movements), atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the walls in the heart), cerebral aneurysm (bulge or ballooning in a weakened area of a blood vessel 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, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 5 residents (Resident # 1 and #2) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1 and #2's wheelchair was maintained. These failures could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life. Findings included: 1. Review of Resident #1's face sheet, dated 03/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acquired absence of left leg above the knee, heart failure, End stage renal disease, other osteomyelitis lower leg (Osteomyelitis -infection in the bone that can be cause by bacteria or fungal). It was reflected Resident #1 was in the facility from 02/19/2025 through 02/28/2025. Review of Resident #1's admission MDS Assessment, dated 03/04/2025, reflected…

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 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 two (Resident #1 and Resident #2) of five residents reviewed for resident rights. The facility failed to: 1.) Ensure CNA C was not on his phone during peri care with Resident #1 on 02/12/25. 2.) Ensure Resident #2 was not ambulating through the facility without a dignity (privacy) bag covering his foley catheter bag on 02/25/25. These deficient practices could place residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth. Findings included: 1.) Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dysphagia…

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 residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #1) of three residents reviewed for enteral nutrition. The facility failed to keep Resident #1's head of her bed elevated at least 30 degrees while receiving enteral nutrition through a g-tube for approximately an hour on 02/17/25. She was found to have difficulty breathing and foam/secretions in and around her mouth. This failure could place residents at risk of tube malfunction, aspiration, and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), disease of digestive system, cerebral infarction (stroke), vascular dementia (dementia caused by brain damage from impaired blood flow), and muscle weakness. Review of Resident #1'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 interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 4 of 4 residents (Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for baseline care plan. The facility failed to initiate a baseline care plan within 48 hours of the admission date for Resident #3, Resident #4, Resident #5, and Resident #6. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs were met. Findings included: Record review of Resident #3's Face sheet, dated 01/02/2025, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: respiratory failure, end stage renal disease (last stage of kidney failure), diabetes,…

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, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 3 residents (Resident #3, Resident #5, and Resident #6) reviewed for care plans. The facility failed to develop a person-centered care plan for Resident #3, Resident #5, and Resident #6. This deficient practice could affect residents and place them at risk for not having their needs and preferences met. Findings included: Record review of Resident #3's Faces sheet, dated 01/02/2025, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: respiratory failure, end stage renal disease (last stage of kidney failure), diabetes, high blood pressure, protein calorie malnutrition and tracheostomy…

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 residents with respect and dignity for 1 of 7 (Resident #2) residents reviewed for dignity in that: The facility failed to ensure staff closed Resident #2's door and pull the privacy curtain closed while changing the resident. This failure could affect residents and place them at risk for psychosocial harm due to a diminished quality of life. The findings were: Record review of Resident #2's Face sheet, dated 01/03/2025, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: heart failure, diabetes, high cholesterol, epilepsy (seizure disorder), dementia (memory, thinking, difficulty), arthritis, morbid obesity, major depressive disorder, insomnia (difficulty sleeping), reflux, muscle weakness, paranoid schizophrenia (mental disorder), cognitive communication deficit (problems with communication), lack of coordination, and reduced mobility. Record review of 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.

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 for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 7 residents reviewed for ADL's. The facility failed to ensure Resident #1 had clean sheets on her bed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #1's Faces sheet, dated 01/02/2025, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: respiratory failure, muscle weakness, abnormal posture, lack of coordination, dysphagia (difficulty swallowing), post-polio syndrome (muscle weakness from polio), heart block, anxiety, high cholesterol, high blood pressure, insomnia (difficulty sleeping) and infarction of spinal cord (stoke in the spinal cord).…

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 residents maintained acceptable parameters of nutritional status for one (Resident #2) of five residents reviewed for nutrition. The facility failed to ensure Resident #2 maintained acceptable parameters of nutritional status as demonstrated by Resident #2 experiencing a 25.38% weight loss in six months. He had an active decline in his weight from 05/01/24 - 11/01/24. This failure could place residents at risk for decreased nutritional status, decline in health, malnutrition, or hospitalization. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including diabetes, reduced mobility, muscle weakness, and feeding difficulties. Review of Resident #2's quarterly MDS assessment, dated 10/18/24, reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities) reflected he required substantial/maximal…

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 one (Resident #1) of five residents reviewed for quality of care. The facility failed to assess complete a skin assess when Resident #1 acquired a skin tear on 11/19/24. Four treatments were missed and he developed an infection requiring antibiotics. These failures placed residents at risk of improper wound management, the development of new skin integrity issues, deterioration in existing skin integrity, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected a 47-year-ole male who was admitted to the facility on [DATE] with diagnoses including cerebral infraction (stroke), type II diabetes, unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's quarterly MDS assessment, dated 10/28/24,…

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 notice before discharge was provided to 1 (Resident #1) of 3 residents reviewed for transfer/discharge, in that: Resident #1 and/or their representative were not provided a written notice of discharge prior to being discharged out of the facility. The Ombudsman was not provided a copy of the notice. This failure had the potential to affect the resident by not having the knowledge of why the resident was discharged , emotional distress, decline in quality of life, disregarding the residents rights, how to appeal the discharge, and the right to appeal the discharge. Findings include: Record Review of Resident #1's Face sheet dated 11/07/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis included respiratory failure, type 2 diabetes mellitus without complications (high blood sugar), muscle weakness, lack of coordination, hypertension (high blood pressure), 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 record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights, in that: The facility failed to provide documentation that Resident #1 received sufficient preparation and orientation when she was discharged home, to ensure a safe discharge. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings Included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a neurological disorder that occurs when a chemical imbalance in the blood affects the brain), sequelae of cerebral infarction (symptoms after a stroke), chronic pulmonary embolism (a long-term condition where one or more blood clots form in the 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 observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 4 of 5 residents (Resident ' s #81, #15, #44, and #7) reviewed for resident rights. The facility failed to ensure Resident #81 ' s call light was within reach on 08/06/24 and 08/07/24. The facility failed to ensure Resident #15 ' s call light was in reach on 08/07/24. The facility failed to ensure Resident #44 ' s call light was in reach on 08/07/24 and 08/08/24. The facility failed to ensure Resident #7's call light was within reach on 08/11/24. This failure could place residents at risk of needs not being met. Findings included: 1. Record Review of Resident #81's medical diagnosis dated 08/06/24 reflected the resident was a [AGE] year old male admitted on [DATE]. His diagnoses included diabetes (a group of diseases that…

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 provide a safe, clean, comfortable, and homelike environment for 3 of 8 residents (Resident #13, Resident#17, and Resident #63) reviewed for resident rights. The facility failed to ensure Resident #13, Resident#17, and Resident #63 to provide a safe bedroom free from obstacles with closets accessible to the resident . This failure could place residents at risk for falls and rooms being overheated from the air conditioner being turned off. Findings included: 1. Record review of Resident #13 undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13 had a diagnosis of Paralytic syndrome (a condition of muscle wasting and loss of reflexes), Multiple sclerosis (an autoimmune disease that damages the central nervous system), and headaches. Record review of Resident #13 Annual MDS assessment dated [DATE] reflected BIMS score of 15 indicating Resident #13 was cognitively intact.…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made for 1 of 20 residents screened for abuse (Resident #11). The facility failed to immediately report to the State Agency (within 2 hours) an allegation of sexual abuse made by Resident #11 on 03/11/2024 and 08/09/2024, and additionally when staff had knowledge of allegations of rape as reported to the PMHNP as collateral information on 07/12/2024 and 08/02/2024. This deficient practice delayed the investigation for the allegation and could have placed residents at risk for abuse and could have resulted in undetected abuse and/or decline in feelings of safety and well-being or psychosocial harm. Findings included: Review of Resident #11's face sheet, dated 08/09/2024, reflected a [AGE] year-old male who…

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 residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 3 of 15 residents (Resident #79, Resident #66, and #68) reviewed for ADLs. The facility failed to ensure Residents #79 was provided assistance with ADLS and eating as documented in his plan of care which made him feel frustrated and that nobody cared about him. The facility failed to provide regular showers to Residents #66 and #68 in accordance with their plan of care. This failure could place residents at risk of weight loss, malnutrition, loss of dignity, and emotional distress. Findings included: Resident #79 Record review of resident #79's face sheet, dated 08/08/24, admission date 09/01/23, documented an [AGE] year-old male diagnosed with Rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood, cirrhosis of liver, alcohol…

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 the resident had a right to be treated with respect and dignity for 1 (Resident #81) of 5 residents reviewed for dignity. The facility failed to ensure Residents #81's urinary bedside drainage bag was placed in a privacy bag on 08/06/24 and 08/07/24. This failure could have compromised residents' dignity for those who require tubing and a urinary bedside drainage bag. Findings included: Record review of Resident #81's medical diagnosis dated 08/06/24 reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included diabetes (a group of diseases that result in too much sugar in the blood), Fractured Right Humerus (break in the upper arm bone), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness), and end stage renal disease (gradual loss of kidney function). Record review of Resident #81's quarterly MDS assessment dated [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 Resident #57 Based on interviews and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 2 of 8 residents (Resident #57 and Resident #61) reviewed for notification of changes. A. The facility failed to ensure the physician was notified of Resident #57 refusing his medication Mirtazapine (a medication for depression) and Risperidone (a medication used to control his schizophrenia). B. The facility failed to ensure the physician was notified of Resident #61 was refusing his medications Coreg (a medication used to treat his heart failure). This failure could place residents at risk of not receiving appropriate medical treatments, which could result in severe illness or hospitalization. Findings included: A. 1. Record review of Resident #57's undated face sheet reflected the resident was a [AGE] year-old male with an admission date of 06/26/24. Resident #57's had diagnoses which included Unspecified Dementia (forgetfulness), Schizophrenia (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 20 residents (Resident #74) reviewed for freedom from physical restraints. The facility failed to ensure Resident #74 was free from restraint when Resident #74 was left sitting in a Geriatric (elderly) chair with the feeding tray fully attached throughout the day. This failure could unnecessarily inhibit the resident's freedom of movement or activity and could affect residents by placing them at risk of physical harm, pain, mental anguish, emotional distress, and serious harm. Findings included: Review of Resident #74's face sheet dated 08/06/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including degenerative disease of the nervous system (chronic conditions that damage and destroy parts of the nervous…

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 comprehensive person-centered care plan furnishing services to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #61) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #61 right to refuse medication and refusals of medications prior to survey. 2. The facility failed to care plan Resident #61 wishes to self-administer vitamin supplements prior to survey. 3. The facility failed to accuracly care plan Resident #68's diagnoses of malnutrition (protein or calorie) by care planning for a recommended diet for weight reduction and not weight gain. This failure placed residents at risk of their needs having gone unmet. Findings included: Record review of Resident #61's undated face sheet reflected the resident was a [AGE] year-old male with an admission date of 05/10/24. Resident #61's had diagnoses which included Type 2 diabetes…

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 respiratory care was provided consistent with professional standards of practice for 1 (Resident #5) of 8 residents reviewed for respiratory care. The facility failed to ensure Resident #5's Oxygen tubing was changed every seven days and there was water filled in the humidifier daily. This failure could place all residents who use respiratory equipment at risk for respiratory complications including infections. Record review of Resident #5 undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had a diagnosis of Chronic Obstructive Pulmonary Disease (a disorder affecting the lungs making it difficult to breath), Hypertension (elevated blood Pressure), and Heart Failure. Record review of Resident #5s admission MDS dated [DATE] reflected Bims score of 14 indicating Resident #5 was cognitively intact. Section GG of the MDS reflected Resident #5 required substantial/maximal…

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 residents' drug regimen were adequately monitored and free from unnecessary drugs for 1 (Resident #54) of 8 residents reviewed for pharmacy services. The facility failed to monitor Resident #54 for side effects/adverse reactions (bruising bleeding,dark black bowel movements) or the use of Eliquis (an anticoagulant medication- blood thinner) prior to survey. These failures could place residents at risk of bruising, and bleeding. Findings included: Record review of undated face sheet reflected Resident #54 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #54 had the following diagnoses of End Stage Renal Disease (kidney failure), Diabetes Type 2 (elevated blood sugars), Heart Failure, and Hypertension (elevated blood pressure). Record review of Resident #54s Quarterly MDS dated [DATE] reflected she had a BIMs score of 14 indicating resident was cognitively intact. The MDS also reflected Resident #54 required assistance 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 observation, interview, and record review, the facility failed to maintain a medication administration error rate below 5% for 3 of 25 (error rate 12%) opportunities for errors during medication pass. 1)The facility failed to administer Resident # 34 his folic acid tablet during the medication administration observation. 2) The facility failed to administer Resident #76 his probiotic capsule and his men's multivitamin with minerals during the medication administration observation. This failure could place residents at risk of not receiving the intended therapeutic effects of medications. Findings included: 1. Record review of undated face sheet reflected Resident #34 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #34 had the following diagnoses of Neuropathy (nerve pain), Chronic Viral Hepatitis (a condition causing liver failure), Muscle Weakness, and Delusional Disorder. Record review of Resident #34s admission MDS dated [DATE] reflected she had a BIMs score of 14 indicating…

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 residents had the right to self-administer medications and safely store medications in room if the IDT determined that the practice was clinically appropriate for one of eight residents (Resident #61) reviewed for medication self-administration. The facility failed to assess for IDT approval for Resident #61 to self-administer his medication and did not provide a secure area in the resident's room to store the medications prior to surveyor entry. This failure could place residents at risk of consuming unsafe medications. Findings included: Record review of Resident #61's undated face sheet reflected the resident was a [AGE] year-old male with an admission date of 05/10/24. Resident #61's had diagnoses which included Type 2 diabetes mellitus without complications (an impairment in the way the body regulates and uses sugar), Aortic Valve Stenosis (a thickening of the heart valves), and Congestive Heart Failure (a weakening of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #68) of twenty residents reviewed for accurate clinical records, in that: The facility failed to ensure Resident #68's medication administration record accurately reflected the medications Resident #68 received. Findings included: Record review of Rresident #68's face sheet, dated 08/08/24, admission date 05/28/24 and 07/27/24, documented an [AGE] year-old male diagnosed with unspecified protein-calorie malnutrition, anxiety, bilateral primary osteoarthritis of knee, limitation of activities due to disability, and need for assistance with personal care. Record review of Resident #68's initial MDS dated [DATE] reflected resident had a BIMS score of 6 indicating the resident was severely cognitive impaired. Section GG - Functional Abilities and Goals at admission reflected Resident #68 had the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow…

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 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 2 (Resident #57, and Resident #61) of 8 residents reviewed for infection control. The Medications Assistant failed to preform hand hygiene before and after medication administration between Resident #57, and Resident #61 61 during the morning medication pass. These failures have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral or secondary infections and communicable diseases. Findings included: Record review of Resident #57's undated face sheet reflected the resident was a [AGE] year-old male with an admission date of 06/26/24. Resident #57's had diagnoses which included Unspecified Dementia (forgetfulness), Schizophrenia (a serious mental illness that…

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 residents/resident representatives were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for one (Resident #1) of three residents reviewed for consents. The facility failed to obtain written consent from Resident #1's Representative (RP) before administering her Ativan (for anxiety) and Depakote (for behavioral issues). This failure could place residents at risk of not having their preferred responsible party represent them in medical and care decisions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), major depressive disorder, and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a need to alter treatment significantly for one (Resident #1) of three residents reviewed for changes in treatment. The facility failed to obtain written consent from Resident #1's Representative (RP) before administering her Ativan (for anxiety) and Depakote (for behavioral issues). This failure could place residents at risk of not having their preferred responsible party represent them in medical and care decisions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), major depressive disorder, and other specified persistent mood disorders. Review of Resident #1's quarterly…

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 medical record contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition for 1 (Resident #1) of 4 residents review for resident assessments. The facility failed to ensure Resident #1's bruises identified on 04/26/24 were reflected in Resident #1's skin assessments. This deficient practice could place residents at risk for inadequate care due to inaccurate assessments. Findings included: Record review of Resident #1's admission Record, dated 06/28/24, revealed Resident #1 was a [AGE] year old female admitted on [DATE], her own RP, and had diagnoses including muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), Alzheimer's disease with late onset (A progressive disease that destroys memory and other important mental functions),…

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 medical records in accordance with accepted professional standards and practices, in that the facility did not completely and accurately document the treatment administration for 1 (Resident #1) of 3 residents reviewed for Treatment Administration Records. The facility failed to document the wound care to Resident #1, as ordered by the physician. This failure could place residents at risk of delay in wound infection and healing process. Findings Included: Record review of Resident #1's admission record dated 06/14/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Cerebral Infarction (stroke), Dysphagia (difficulty in swallowing), Acute Respiratory Failure, Type 2 Diabetes Mellitus, Heart failure, Hypertension, Major Depressive Disorder, Obesity, Hyperlipidemia (excess fat in blood) ,), Muscle Weakness and, ,Lack of coordination. Record review of Resident #1's initial MDS…

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect result in bodily injury, to other officials (including the State Agency) for 1 (Resident #5) of 10 residents reviewed for abuse, neglect, and misappropriation of property, in that: The facility failed to report to the State Survey Agency within two hours after Resident #5 alleged he was abused by Housekeeper D on 02/24/24 at 7:00 p.m. This failure could place residents at risk of feeling unsafe, injury, and revictimization by the same alleged perpetrator. Findings included : Record review of Resident #5's admission record, dated 03/20/24, revealed he was a male resident who was admitted to the facility on [DATE], his own RP and had diagnoses including sequela…

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 and prevention control program that included, at a minimum, a system for preventing and controlling infections for 5 of 7 residents (Residents #128, #5, #53, #127 and #31) reviewed for infection control in that: a) MA A, MA B and MA C did not clean and disinfect the wrist blood pressure monitors when it was used on Resident #128, Resident #127, Resident #31, and Resident #5. b) MA B while providing incontinent care for Resident #53, contaminated the whole packet of wet wipes by pulling out wipes from the packet with unclean gloves. These failures could place the residents at the facility at risk of transmission of diseases and infection. Findings included: a) Record review of Resident #128's face sheet dated 06/26/23 reflected Resident #128 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Hypertensive heart (a constellation of changes in the left ventricle, left atrium, and coronary…

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 effective pest control program in that: 1. Flies were observed in all areas of the facility. These failures placed residents at risk for disease and infection and a diminished quality of life. Findings Include: Observation on 06/26/2023 at 12:45 PM one to five flies at each of the seven tables in the dining area. Observed three residents at one table who actively waived flies away and heard the residents discuss that the flies landed on their food. Observed on 06/26/2023 at 2:00 PM a fly in rooms [ROOM NUMBERS]. Observed on 0/26/2023 between 2:09 PM and 2:26 PM in the dining room three flies on an empty table, a fly in the air, a fly on an incomplete puzzle, 2 additional flies in the air, and seven flies on an empty table. Observation on 06/26/2023 between 12:35 PM and 12:45 PM in the dining room of one fly on the bread of a resident's food; one fly on the lip of resident's drinking cup; one fly on the lid covering 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 interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, or injuries of unknown origin were reported immediately but not later than 24 hours after the allegation was made for one of three residents (Resident #15, Resident #51, and Resident #71) reviewed. The facility failed to report to the State survey agency that Resident #71 was smoking in her room, in the facility, a prohibited smoking area outside the facility and was in possession of illegal drugs and paraphernalia in her and offered the drugs to Resident #15 and Resident #51. This deficient practice placed residents at risk for harm. Findings included: Review of Resident #15's 06/29/2023 face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia ( happens when you don't have enough oxygen in your blood), drug induced subacture dyskensia (involuntary movement disorder), cerebral palsy, (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.