Gracy Woods Nursing Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to date food and beverages found within the facility's freezer and refrigerator on 12/29/2025The facility failed to date and properly seal food products in facility freezer and refrigerator on 12/29/2025. These failures could place the residents who ate food from the kitchen at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness. Findings included:In an observation on 12/29/2025 at 9:15 AM, the facility's one door freezer was found to contain an open undated box of breakfast sausage patties with a partially opened bag of breakfast sausage patties that were exposed to air. The freezer contained a large clear plastic bag with green peas covered with ice. There was no date or label on the bag. The freezer contained 5 individual servings of vanilla ice cream that had leaked into inside of the box and the lids on two of the containers had slid to the side…

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 reviews and interviews, the facility failed to ensure evidence reflects the facility did not complete a discharge summary to include a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge as resident was discharged to the hospital for a change in condition and the family chose to not readmit to the facility for 1 (Resident #94) of 4 residents reviewed for safe transfer or discharge. The facility failed to record the reasons for the transfer/discharge in Resident # 94's medical record when discharged on 11/30/2025. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. Findings included:Record review of Resident # 94's face sheet dated 12/31/2025 reflected a [AGE] year-old female admitted on [DATE] and discharged on 11/30/2025.Record review of Resident # 94's continuity of care document dated 12/31/2025 reflected diagnosis 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 interviews, and record reviews, the facility failed to develop and implement an accurate comprehensive person-centered care plan that met the residents' medical needs and treatment plan for 1(Resident # 38) of 6 residents reviewed for comprehensive care plans. The facility failed to provide interventions / approaches consistent with facility policy of being a non-smoking facility for Resident # 38 vape use listed as a problem on her care plan. This failure could affect residents by placing them at risk of not receiving appropriate interventions and care to meet their current needs.Findings included: Record review of Resident # 38 face sheet dated 12/31/2025 reflected a [AGE] year-old female admitted on [DATE].Record review of Resident # 38 continuity of care document dated 12/31/2025 reflected a diagnosis of unspecified visual loss, cough, pain, age related cataract bilateral (a clouding of the eye's natural lens causing blurry or hazy or dim vision on both eyes), depression, muscle weakness, lack 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 ensure professional staff were licensed certified or registered in accordance with applicable state laws for 13 Nurse Aides of 13 nurse aides reviewed for assessments. The facility failed to ensure NAs A, B, C, D, E, F, G, H, I, J, K ,L ,M, Nurse Aide Curriculum skill performance checklists were checked off. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being.Findings include:Record review of NA A's employee record revealed they were hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 10/03/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA B's employee record revealed they were hired 09/02/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA C's employee record 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 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 update Resident #1's care plan after an X-ray (a form of electromagnetic radiation used in medicine to create images of the inside of the body for diagnostic purposes) result dated 10/17/2025 reflected a nondisplaced fracture of the medial epicondyle (a bony prominence on the inner side of the elbow where muscles and the ulnar collateral ligament (is a circular ligament on the inner side of the elbow that connects the upper arm to the forearm bone) attach ) of the distal end of the right humerus (the long bone in the upper arm, connecting the shoulder blade to the forearm bones.) This deficient practice placed Residents at risk for not getting right interventions, risk for harm…

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 the walk-in refrigerator and walk in freezer. 3. The facility failed to ensure Dietary Manager wore a facial hair restraint while performing duties throughout the kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.Findings included: Observation on 07/29/2025 at 8:15 AM revealed the Dietary Manager had a mustache in which was not covered with a facial hair restraint while he was performing duties in the kitchen area. Observation revealed Dietary Manager was not wearing a facial hair restraint while walking throughout the main kitchen area, food preparation area, and the walk-in refrigerator. 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 observation, interview and record review, the facility failed to provide reasonable accommodations for 2of 6 residents (Resident # 73 and Resident #47) reviewed for resident rights. The facility failed to ensure:*Resident #73 could communicate his needs and preferences. *Resident #47 had access to call light button. These failures could place residents at risk of isolation, not receiving needed care or nursing interventions to meet the resident's needs. Finding included: Record review of Resident #73's Face Sheet dated 06/17/2025, revealed Resident #73 was admitted to the facility on [DATE] and was an [AGE] year-old male with diagnoses of: Insomnia (sleep disorder characterized by difficulty falling asleep), Dysphagia (difficulty in swallowing), Hypertensive Heart disease with heart failure (a condition where high blood pressure (hypertension) over time damages the heart, leading to heart failure), and Paroxysmal atrial fibrillation (irregular heart rhythm). Review of Resident #73's Quarterly MDS, dated…

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 establish and maintain a homelike environment for 2 or 3 residents (Resident #87 and Resident #14) observed for environmental conditions. The facility failed to ensure Resident #87's and Resident #14's bedroom walls were upkept and homelike. This failure could cause residents psychological distress or feel uncomfortable. Based on interview and record review, the facility failed to establish and maintain a homelike environment for 2 or 3 residents (Resident #87 and Resident #14) observed for environmental conditions. The facility failed to ensure Resident #87's and Resident #14's bedroom walls were upkept and homelike.This failure could cause residents psychological distress or feel uncomfortable.Findings Included:Resident #87Record Review of Resident #87's face sheet revealed was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #87 had a diagnosis of schizoaffective disorder (mental health condition that is marked by symptoms…

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 each resident for 3 of 5 residents (Resident #44 and Resident #41 and #103 of 4 medication carts MC A reviewed for pharmaceutical services. 1. The facility failed to document controlled medications from the medication cart on the narcotic count sheets for Resident #44, Resident #41, and Resident #103. 2. The facility failed to remove a discontinued bottle of controlled medication from the medication cart for Resident #103. This failure could place residents at risk of medication errors and drug diversion.Findings include: Record review of Resident #44's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included displaced intertrochanteric fracture of right femur, muscle spasms, acute pain due 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 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 3 of 7 residents (Resident #2, Resident #63, and Resident #33) and 2 of 5 staff (LVN C and CNA A) reviewed for infection control. 1. The facility failed to ensure CNA A was conducting hand hygiene between each resident when passing lunch trays on hall 500. 2. The facility failed to ensure LVN C was sanitizing surfaces before and after when providing wound care for Resident #2, Resident #63, and Resident #33.These failures could place residents at risk of transmission of disease and infection. Findings included: Observation on 07/29/25 at 12:21 pm on hall 500 hall revealed CNA A pushed the meal cart down the hall. Without conducting hand hygiene CNA A picked up a tray and brought it to Resident #2's room. CNA A then…

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 routine and emergency drugs and biologicals for 1 of 4 residents (Resident #1) reviewed for pharmacy services.1. The facility failed to ensure Resident #1's ciprofloxacin-dexamethasone (antibiotic ear drops) was acquired and administered according to 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: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 face sheet reflected a [AGE] year-old male admitted on [DATE] 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.

Based on interview and record review, the facility failed to include effective communications as mandatory training for 16 of 16 employees (MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW) reviewed for training requirements. The facility failed to provided MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ AND SW 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 S's personnel record had a hire date of 06/16/15, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA T's personnel record had a hire date of 02/09/16, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of MA U's personnel record had a hire date of 05/18/20, with annual training in-services provided by…

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 training on the QAPI program to outline and inform staff of the elements and goals of the facility QAPI program for 16 of 16 employees (MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW) reviewed for training requirements. The facility failed to provide MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ AND SW on the QAPI program as mandatory training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA S's personnel record had a hire date of 06/16/15, with annual training in-services provided by the facility that did not include evidence of the QAPI program as mandatory training. Review of CNA T's personnel record had a hire date of 02/09/16, with annual training in-services provided by the facility that did not include evidence of the QAPI program as mandatory training. Review of MA U's personnel record had a hire date of 05/18/20, 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.

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 16 of 16 employees (MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW) reviewed for training requirements. The facility failed to provide MDS, CNA S, CNA T, CNA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ AND SW on the compliance and ethics program's standards, policies and procedures through a training program or other practical manner as required. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA S's personnel record had a hire date of 06/16/15, with annual training in-services provided by the facility that did not include evidence of the compliance and ethics program's standards, policies and procedures as required. Review of CNA T's personnel record had a hire date of 02/09/16, with annual…

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 housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 5 of 24 resident rooms for Residents #69, #74, #31, #12, #15 whose rooms were observed for housekeeping and maintenance services. 1. Resident #69's room did not have a pull string for the overhead light, the wall paper on the wall behind the head of the bed was peeling off, the cover to a drawer on the right bottom closet was missing, and the privacy curtain was torn from the top and the torn portion was used to tie the bottom of the curtain so it would not drag on the floor. 2. The facility failed to provide a functional accessible bathroom and a functioning light switch with a plate cover in Resident #74's room. 3. The facility failed to ensure room [ROOM NUMBER] did not have a broken base board, peeling wallpaper, and missing toilet tank top cover. 4. The facility failed to ensure Resident #31's room did not have 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 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 5 of 21 residents (Resident #13, #31, #70, #69, and #74) reviewed for care plans: 1. The facility failed to ensure Residents #13's Care Plan reflected they refused staff assitance with their personal refrigerated items. 2. The facility failed to ensure Residents #31's Care Plan reflected they refused staff to assist with their personal refrigerated items. 3. The facility failed to ensure Residents #70's Care Plan reflected they refused staff to assist with their personal refrigerated items. 4. The facility failed to revise Resident #69's comprehensive care plan to reflect the resident no longer received a puree textured diet or crushed…

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 all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 8 medication carts and 2 of 21 Residents (Resident #72 and #84) reviewed for labeling and medication storage: 1. The facility failed to ensure the medication cart used on the 200-unit had pharmacy labels on 7 out of 11 insulin pens in the cart, medications were not left on the mediation cart counter, and the medication cart was locked. 2. The facility failed to ensure the medication cart used on the 400-unit was locked and medications were not left on the medication cart counter. 3. The facility failed to ensure Resident #72 did not have medicated mentholated ointment (combination product that is used to relieve itching, minor muscle, or joint pain. This product may also be used as a chest rub to soothe symptoms associated with the common cold.) at his bedside. 4.…

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 employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 6 (DA K, DA L, DA M, DA N, DW P, and DA O ) of 10 dietary staff reviewed for qualified dietary staff, in that: The facility failed to ensure the DA K, DA L, DA M, DA N, DW P, and DA O had their Texas Food Handler Certificate. This failure could place residents who ate food from the facility's kitchen at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings included: Record review of four (4) certificates with completion dates ranging from 6/8/23 to 2/24/25. Certificates were titled Texas Food Handler Certification and indicated, renewal due 2 years from completion date. It was noted that certificates for DA K, DA L, DA M, DA N, DW P, and DA O were not found in this stack of certificates. During an interview on 2/26/25 at 5:35 p.m. the DS stated DA K, DA L, DA M, DA N, DW P, and DA O just washed dishes and he did not think they need a…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to have hand soap at the handwashing station in the kitchen. 2. The facility failed to keep dish racks and juice lines off the floor. 3. The facility failed to not store a basket of milk cartons on the walk-in cooler floor. 4. The facility failed to date an open package of turkey and 2 open bags shredded cheese. 5. The facility failed to date a container of onions, discard a rotten potato, close a bag of grits, and to store an open bottle of sauce in the refrigerator. 6. The facility failed to cover Resident #36's lunch tray when placed on the hallway cart. 7. The facility failed to ensure the ice machine was clean and there was a cleaning log. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. During an observation on 2/25/25 at 9:10 a.m. the kitchen…

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 enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 (Residents #70 and #31) of 3 residents reviewed, in that: 1. Resident #70's personal refrigerator was observed to have spoiled food and no temperature log. 2. Resident #31's personal refrigerator was observed to have expired food and an incomplete temperature log. This deficient practice could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: 1. During an observation on 2/25/25 at 9:53 a.m. Resident #70 had a personal refrigerator. There were many containers of lunch meat on a dresser and in the resident's bed. Some of the containers of lunch meat had green spots. On a bedside table were numerous bottles with liquid stains on the outside of them. Resident #70 stated staff did not help him discard of food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5 of 21 residents (Resident #89, Resident #67, Resident #40, Resident #66, and Resident #74) reviewed for infection control: 1. The facility failed to ensure LVN A practiced proper hand hygiene when administering medications to Resident #89, Resident #67, and Resident #40. 2. The facility failed to ensure LVN J wore a gown during peg tube medication administration for Resident #66 who had orders for EBP and did not contaminate her gloves. 3. The facility failed to ensure Resident #74's indwelling urinary catheter bag was not on the floor. These failures could place residents at-risk for infection due to improper care practices. The findings included: 1. a. Record review of Resident #89's face sheet dated 2/26/25 revealed a [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.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. The facility failed to ensure 1 of 2 washing machines and 1 of 2 dryers were operable. These failures could place residents at risk of needs not being met due to equipment not being operable. The findings included: A record review of the facility's resident roster dated 2/24/25 revealed a census of 84 residents. During the Resident Council meeting conducted on 2/26/25 at 10:08 a.m., residents revealed the facility had only 1 out of 2 washers and 1 out of 2 dryers that were operable and would often break down. Residents also revealed the laundry is often backed up. During an observation and interview on 2/28/25 at 7:53 a.m., the Laundry Assistant Manager stated, the facility had two washing machines and two clothes dryers, but only 1 washer and 1 dryer were operable. The Laundry Assistant Manager stated 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.

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 09 of 16 employees (CNA W, CNA Y, DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW ) 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 W, CNA Y, DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW. 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 W's personnel record had a hire date of 06/01/21, 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 Y's personnel record had a hire date of 10/20/23, with annual training in-services provided by the facility that did not include evidence 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 the mandatory training on standards, policies, and procedures for an infection prevention and control program for 7 of 16 staff (DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW. This failure could place residents at risk of illness due to lack of staff training. The findings were: Review of DS's personnel record had a hire date of 05/22/23, with annual training in-services provided by the facility that did not include evidence of education on infection control topics. Review of Act D's personnel record had a hire date of 12/02/24, with annual training in-services provided by the facility that did not include evidence of education on infection control topics. Review of LVN FF's personnel record had a hire date of 11/19/21, with annual training in-services provided by the facility that did not include evidence of education on infection control…

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 behavioral health training for 15 of 16 employees (MDS, CNA S, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to MDS, CNA S, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of MDS's personnel record had a hire date of 12/17/21 revealed no evidence of behavioral health training. Review of CNA S's personnel record had a hire date of 06/16/15 revealed no evidence of behavioral health training. Review of MA U's personnel record had a hire date of 05/18/20, revealed no evidence of behavioral health training. Review of CNA V's personnel record had a hire date of 09/16/19 revealed no evidence of behavioral health training. Review of CNA W's personnel record had a hire date of 06/01/21 revealed no evidence 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, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 8 residents (Resident #36) reviewed for grievances. The facility failed to fully investigate and address Resident #36's grievance report of missing personal property, including two computers, a wallet, DVDs, and food items, and did not assist Resident #36 in replacing his identification and bank card. This failure could place residents at risk for not having their grievances resolved. The findings included: Record review of Resident #36's continuity of care document (CCD), dated 2/28/25, revealed a [AGE] year-old male resident was admitted on [DATE] with diagnosis that included multiple sclerosis (a chronic autoimmune disease that affects the central nervous system), disorder of brain, and age-related physical debility. Record review…

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 were free from Misappropriation of property for one (Resident #36) of 8 residents reviewed for misappropriation of property. The facility failed to ensure Resident #36 was free from misappropriation of property when he was forced to leave his room and belongings after a bed bug infestation and when he returned his wallet, DVDs, snacks, and two laptops were missing. This failure could place residents at risk of Exploitation/Misappropriation of Property and financial distress. Findings include: Record review of Resident #36's continuity of care document (CCD), dated 2/28/25, revealed a [AGE] year-old male resident was admitted on [DATE] with diagnosis that included multiple sclerosis (a chronic autoimmune disease that affects the central nervous system), disorder of brain, and age-related physical debility. Record review of Resident #36's annual MDS assessment, dated 12/9/24, revealed his cognition was intact for daily…

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 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 if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 1 (Resident #36) of 8 residents reviewed for abuse. The facility failed to report to the state agency when Resident #36 alleged his wallet, DVDs, snacks, and two laptops were missing. This failure could place residents at risk of Exploitation/Misappropriation of Property and financial distress. Findings include: Record review of Resident #36's continuity of care document (CCD), dated 2/28/25, revealed a [AGE] year-old male resident was admitted on [DATE] with diagnosis that included multiple sclerosis (a chronic autoimmune disease that affects the central nervous system),…

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 the observations, interviews, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 2 (Resident #47, and Resident #70) of 21 residents reviewed for accidents. 1. The facility failed to ensure Resident #47 did not have an insulin needle on her bedside table. 2. The facility failed to ensure Resident #70 did not have a power strip in his room and a fan plugged into it. This failure could place the resident at risk of hazards and/or accidents. Findings included: 1. Record review of Resident #47's CCD 2/28/25, documented a [AGE] year-old female admitted to facility's secure unit on 10/19/24 with diagnoses, type 2 diabetes mellitus (a chronic health condition that affects how the body turns food into energy), depression, hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), and anxiety disorder (a mental health disorder characterized…

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 required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #21) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #21. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #21's face sheet, dated 2/28/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses that included type 2 diabetes (chronic condition in which the body become resistant to insulin or doesn't produce enough insulin to maintain normal glucose levels), and chronic kidney disease stage 5 (also known as end stage renal disease; when the kidneys have lost nearly all of their…

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 each resident for 2 of 8 residents (Residents #69 and #66) reviewed for medications and pharmacy services: 1. MA D prepared Resident #69's medications and allowed LVN A to administer them to the resident. 2. The facility failed to ensure LVN J administered all of Resident #66's arginine-based powder mixture (designed to support the unique nutritional needs of people with chronic wounds. It delivers 4.5 grams of L-arginine and Vitamins C and E for wound management.) via his PEG tube (is a surgery to place a feeding tube. Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach.) These deficient practices could put residents at risk for inaccurate or inappropriate administration of medications. The findings included: 1. 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.

Based on observation, and interview the facility failed to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #1) reviewed for disposal of garbage. The facility failed to ensure Dumpster #1 was closed and trash was not on the ground outside the dumpster and around the facility grounds. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: During an observation on 2/25/25 at 11:02 a.m. revealed the side door to dumpster #1 was open. During an observation on 2/26/25 at 5:41 p.m. revealed the side door to dumpster #1 was open. On the ground behind the dumpster was a food wrapper, used gloves, and used masks. During an interview on 2/26/25 at 5:41 p.m. the DS stated the dumpster should not be open but is shared with the whole facility and sometimes others leave it open. The DS stated the trash on the ground and the open dumpster can attract animals and should not be there. The DS stated maintenance was in charge of pick up trash off the facility grounds outside. During an interview…

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 medical records on each resident that were complete and accurately documented for 2 of 21 residents (Residents #69 and Resident #74) reviewed for medical records. 1. The facility failed to ensure Resident #69's physician's orders were updated to include the resident no longer received a puree diet, thickened liquids, and crushed medications. 2. The facility failed to ensure Resident #74's physician's orders were updated to include the resident was a DNR status. These deficient practices could place residents at risk of improper care due to inaccurate medical records. The findings included: 1. Record review of Resident #69's face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dysphagia-oropharyngeal phase (difficulty swallowing due to dysfunction in the mouth and throat), and vitamin deficiency. Record review of Resident #69's most recent annual MDS assessment dated…

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, record reviews, and interviews the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 1 (Resident #66) of 21 rooms reviewed for full visual privacy. The facility failed to provide Resident #66 with a privacy curtain. This failure could cause a decrease in feelings of self-worth by being exposed during cares. Findings included: 1. Record review of Resident #66's CCD, dated 2/28/25, revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (when the blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes.), gastrostomy status (presence of an artificial opening in the stomach), pressure ulcer of unspecified part of back stage 4, protein calorie malnutrition, anemia (where there are insufficient healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), 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 maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 6 residents (Residents #1 and Resident #2) reviewed for infection control, as indicated by: CNA A, CNA B and CNA C failed to change dirty gloves while handling clean items while providing peri care to Resident #1 and, Resident # 2. This failure could place the residents at risk of transmission of diseases and infection. Findings included: Review of Resident #1's face sheet dated [DATE] reflected, Resident #1 admitted to the facility on [DATE] She was a [AGE] year-old female diagnosed with Pain, Iron deficiency, Vitamin deficiency, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Insomnia, Hypertension and Age-related physical debility. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected her BIMS was 03 indicating her cognition was severely impaired. Record review…

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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart and ensure infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and including infection control practices for mechanical ventilation/tracheostomy care including the use of humidifiers were followed by staff for 1 (Residents #1) of 5 residents reviewed for respiratory care, The facility failed to ensure Resident #1's nasal cannulas and tubing were properly stored when not in use. This deficient practice could place residents at risk of cross-contamination and illness. Findings included: Record review of Resident #1's Face Sheet, dated 05/20/24, revealed a [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 develop and implement a comprehensive person-centered care plan 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 4 residents reviewed (Resident #2) reviewed for care plan, in that: The care plan for Residents #2 failed to address any of the resident's need, because Resident #2 did not have a care plan. These failures could affect the resident by placing him at risk for not receiving care and services to meet his needs. Findings included: Review of Resident #1's initial MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Further review of the sections revealed: C - Cognitive Patterns reflected he had a BIMS of 12 (suggesting moderately impaired cognition) with disorganized thinking, Section H - Bladder and Bowel reflected he had an Ostomy (a life-saving…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observations of the facility's kitchen refrigerator on 04/01/2024 at 9:22am revealed the following items were not sealed and exposed to air, labeled, or dated: Two plastic bags of cheese not dated, labeled, and sealed. One plastic bag of ham deli meat not dated, labeled, and sealed. 4 Prepped cups of orange juice not dated, labeled. Milk in a pitcher not dated and labeled. 8 Prepped cups of ketchup, ranch and thousand island dressing not dated and labeled. A container of strawberries not labeled and dated. One plastic bag of lettuce not labeled and dated. Observations of the facility'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 observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 16 (Resident #1, and Resident #2) residents in 1 of 1 dining room. The facility failed to promote Resident #1 and 2's dignity while dining when staff did not serve the residents their lunch tray at the same time as other residents at the same table. This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Review of Resident #1's Face Sheet dated 004/01/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, type 2 diabetes, high blood pressure, insomnia, heart failure, respiratory disease, depression, protein-calorie malnutrition, high levels of fat particles in the blood, psychoactive substance…

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 resident rights for personal privacy for two of seven (Resident # 3, and Resident # 4) residents observed for resident rights. CNA B and CNA C did not provide privacy to Resident #4 when providing care. The facility failed to provide privacy to Resident #3 while she was lying in bed with no clothing on from the waist down. The deficient practice could affect all residents in the facility by placing them at risk for loss of dignity and privacy. Findings included: Review of Resident #3's Face Sheet dated 04/01/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included dementia, obesity, insomnia, anxiety disorder, high blood pressure, long term use of aspirin, reflux disease, constipation, muscle spasm, chest pain, pain, convulsions, and protein-calorie malnutrition . Record Review of Resident #3's MDS revealed her BIMS was a 13 cognitively intact. Resident #3 is 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 each resident had the right to be free from abuse for 2 residents (Resident #1 and Resident #2) of 7 residents reviewed for abuse/neglect. CNA A called Resident #1 dumb and asked why he can't change himself when he asked for assistance on Thursday, 3/7/24 at approximately 8:30 pm. Resident #1 stated CNA A's words made him feel embarrassed and angry. Resident #3 entered the room of Resident #2 on Saturday 3-02-24, and hit Resident #2 on the foot 4 times. This failure could place residents at risk of fear and physical/psychosocial injury. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of anemia, nutritional deficiency, meningitis (infection in spinal cord), GERD, pain, muscle spasm, unspecified convulsions/epilepsy, depression, TBI (traumatic brain injury), hydrocephalus (swelling in brain), and metabolic encephalopathy (A medical…

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 a resident who requires dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for three (Resident #1, Resident #2, and Resident #3) of four residents reviewed for dialysis, in that: The facility failed to ensure current active physician's orders for the type or frequency of dialysis treatments were in place for Resident #1, Resident #2, and Resident #3 and that physician's orders were in place for monitoring the dialysis access site for Resident #1. These failures could place residents on dialysis at risk of severe blood loss, infection control complications, and hospitalization. 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 end-stage renal disease, type II diabetes, and dependence on renal dialysis (a process…

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.