Harmony Care at Beaumont

Based on interview and record review the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 8 of 8 months reviewed for RN coverage. * The facility did not have RN coverage every day in April 2025, May 2025, June 2025, August 2025, September 2025, October 2025, and November 2025.* The facility did not have an RN for 8 consecutive hours every day in April 2025, May 2025, June 2025, July 2025, and August 2025.These failures could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings included: During an interview on 12/02/25 at 10:16 a.m. the Administrator said on the Exel form of the RN hours the Raw Hours were potential hours to work and the Work Hours were the actual hours worked. He said he clarified if there were no hours under the Work Hours then the nurse did not work. During an interview on 12/03/25 at 01:56 p.m. HR said there were only 2 RNs employed at the facility-the DON and RN R. Record review of the RN time sheets…

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 follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information. (Quarter 3 2025) *The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2025. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included:Record Review of the facility's Civil Rights form (3761) dated 12/03/25 indicated the following:2 RNs 9 LVNs 20 Direct Care Staff9 Dietary8 Housekeeping & Laundry 6 All OthersRecord review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report) 1705D FY Quarter 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 units (secure unit) and room [ROOM NUMBER] and room [ROOM NUMBER] reviewed for homelike environment. 1.The facility failed to provide home-like furniture in TV room and dining room area just with a table. 2.The facility failed to ensure the walls of room [ROOM NUMBER] and room [ROOM NUMBER] did not have scratches and areas of missing paint. 3.The facility failed to provide a clean and sanitary bathroom for room [ROOM NUMBER]. These failures placed the staff and visitors at risk of living and working in conditions of institution which can lead to decline of mental, social skills and increase of behaviors. Findings included: During an observation on 12/03/25 at 11:30 a.m. revealed a plain table with no placements or tablecloths. The table had no decorations. The dining room area / TV room had bare walls and was not homelike. The…

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

Based on interview and record review the facility failed to implement the written abuse policy that prohibit mistreatment, neglect, and abuse of residents, for 7 of 7 staff reviewed for abuse. (LVN A, LVN F, Former SW, CNA B, CNA G, CNA M, and CNA Q)The facility did not screen potential employees LVN A, LVN F, Former SW, CNA B, CNA G, CNA M, and CNA Q to include attempting to obtain information from previous employers and/or current employers.This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included:Record review of the Abuse and Neglect policy dated June 2023 indicated the following: Policy Statement: It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components 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 observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food items in the dry pantry were labeled, dated, and sealed.This failure could place residents that eat out of the kitchen at risk for foodborne illnesses.Findings include:An observation of dry storage on 12/01/2025 at 8:10 AM indicated the following:*2 large plastic gallon zipper top bags each with an 5-pound, opened and used original container bag labeled cornbread and muffin mix with no use by date or open date,*1, 11-ounce box of vanilla wafers with bag ripped open in the original yellow Nilla wafer box. The tabs were opened, and the bag was not sealed, exposing the wafers to the elements, with no use by date or open date,*1, opened and used 12-ounce bag of Best Choice ribbon pasta not sealed and with no use by date or open date,During an interview on 12/01/2025 at 8:20 AM, the DM said she did not know when or who opened the…

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

Based on interview and record review, the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for Social Worker (SW).The facility did not employ or contract a SW as required by state regulations. This failure could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Findings included:Record review of a employee list provided by the DON on 12/01/25 indicated there was no SW listed. During an interview on 12/01/25 at 01:15 p.m., the VPO said they did not have a SW working for the facility either contract or part-time. He said they had not had one for a couple of weeks. He said they were advertising for a SW but had no responses yet. During an interview on 12/01/25 at 01:21 p.m. HR said they did not have a SW currently. She said the previous one was terminated a couple of weeks ago. Record review of the employee file for the former SW…

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 essential equipment in safe operating condition for 1 or 1 facility kitchen.The walk-in freezer had excessive accumulation of ice build- up.This failure had the potential to affect residents by placing them at risk for food borne illness. Findings were:An observation of the walk-in freezer and interview on 12/01/25 at 9:00 a.m. revealed the temperature was -19. The walk-in freezer had excessive amounts of ice build-up on the top shelf, and around the electrical cord of the freezer fan was a large block of ice build-up appearing to be so heavy, the electrical cord was drooping. There was also ice accumulation on left side of the doorway wall entering the walk-in freezer. There were 30, 1-inch thick, 6-inches long icicles covering the upper left area of the wall. On the ceiling of the walk-in freezer were multiple frozen water drops. The DM said she had talked to the maintenance department about the freezer, but did not have any evidence that a requisition had been made for the repairs needed.During an…

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

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for staff for 1 of 1 facility kitchen floor reviewed for environmental concerns. The floor under the back of the stove was missing 8-10 tiles. These failures could place staff at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment.Findings were:An observation on 12/01/25 at 9:15 a.m. of the kitchen floor revealed the flooring under the back of the kitchen stove, had 8-10 floor tiles were missing. Around the edges, there was a build up of dirt and brown grime.During an interview with the DM on 12/01/25 at 9:20 a.m., she said she had been in the facility for 6 months, and was trying to get things done. She confirmed the condition of the floor missing tiles. The DM said the floor in the kitchen had been like that for several months. The DM said she did not have any evidence that a repair requisition was made for the floor. The DM said the dietary department did not have their own…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 10 residents (Resident #9) reviewed for advanced directives.The facility failed to ensure Resident #9 who was listed as a DNR (Do Not Resuscitate) had valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was not missing required information.This failure could place residents at risk of not having their end-of-life wishes honored and incomplete records.Findings included:Record Review of Resident #9's face sheet, dated [DATE] , indicated a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included: Major Depressive Disorder (a mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest or pleasure in activities), and Schizoaffective disorder bipolar type [a serious mental illness combining symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with mood swings from bipolar disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident drug regimen was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. (Resident #4)* The facility did not have appropriate diagnoses for Resident #4's Abilify (antipsychotic).* The facility did not have behavior monitoring for Resident#4's Lexapro (antidepressant).These failures could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate monitoring or indication for use. Findings included: Record review of a face sheet dated 12/03/25 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included paranoid schizophrenia (a mental disorder characterized variously by hallucinations, delusions, disorganized thinking and behavior, and flat or inappropriate affect with a strong belief that they are being persecuted, spied on, or conspired against by others), schizoaffective 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 observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 16 residents reviewed for accuracy of assessments. (Resident #16) The facility did not accurately complete the MDS assessment to indicate Resident #16 used tobacco. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included:Record review of a face sheet dated 12/03/25 indicated Resident #16 was a [AGE] year-old male admitted on [DATE]. His diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which…

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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 of 3 residents (Resident #16) reviewed for new admissions.The facility did not accurately complete a baseline care plan within 48 hours of admission for Resident #16 to address his smoking.This failure could lead to residents not receiving necessary care and decreased quality of life.Findings included:Record review of a face sheet dated 12/03/25 indicated Resident #16 was a [AGE] year-old male admitted on [DATE]. His diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), cerebral infarction…

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 that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Resident #4) reviewed for care plans. The facility failed to ensure that Resident #4's care plan addressed his psychiatric diagnoses or his psychotropic medications.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings included:Record review of a face sheet dated 12/03/25 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included paranoid schizophrenia (a mental disorder characterized variously by hallucinations, delusions, disorganized thinking and behavior, and…

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

Based on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal laws, 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 1 of 1 treatment carts (treatment cart) of 1 of 3 medication carts (200 Hall cart) reviewed for medication storage. - The facility failed to ensure the medication treatment cart was locked when left unsecured and unsupervised at the main nurse station. - The facility failed to ensure Hall 200 Nurse Cart was locked when left unsecured and unsupervised at the main nurse station. These failures could place residents at risk of adverse reactions to medications, misappropriation of medications and not receiving therapeutic effects of medication.Findings include: During an observation and interview on 12/01/25 at 09:15 a.m., the treatment cart was noted to be unsecured and unsupervised at the main nurse station. Located inside the unlocked medication treatment cart was the following items labeled as…

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 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 during medication pass for 1 of 4 medication carts (Hall 200 medication cart) reviewed for infection control. The facility failed to ensure the Hall 200 medication cart was clean and free of spills and buildup of grime. This failure could place residents at risk for medications being stored in unsanitary cart and infections.Findings included: During an observation and interview on 12/02/25 at 10:20 a.m., medication cart for the long Hall 200 had a buildup of black substance on inside of the second drawer where medications were kept in the drawer. The lower drawer contained bottles of liquid medications that had spills of liquid medications on the bottles and labels. The bottom of the drawer had a sticky substance. LVN C said the cart needed to be cleaned and spills could make labels…

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 follow their own established smoking policy for 1 (Residents #30) of 2 residents reviewed for smoking. The facility failed, on12/03/25, to ensure that Resident #30 did not keep his personal cigarettes and lighter in his possession and was attempting to smoke unsupervised. This failure could place residents at risk of an unsafe smoking environment and injury. Findings included: Record review of Resident #30's comprehensive MDS assessment dated [DATE] indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included high blood pressure, and seizure disorder. Resident #30's BIMS score was 05, indicating his cognition was severely impaired. Record review of Resident #30's care plan dated 05/09/25 indicated he was a tobacco smoker and was at risk for injury. The interventions included to keep his smoking material at the nurses' station and observe, as needed, when smoking to assure resident's safety. 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 observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents in rooms #203, #215, and #220 (three of ten resident rooms) that were observed for physical environment. 1. The facility failed to ensure the rooms and bathrooms for rooms #203, #215, and #220 were clean and free of dead bug carcasses and dead cock roaches on 09/22/2025 and 09/23/2025.2. The facility failed to ensure the bathroom vanity for room [ROOM NUMBER] was in good repair. Two of two doors for the bathroom vanity were missing on 09/23/25. 3. The facility failed to ensure the broken and missing tile was repaired and replaced in the bathroom for room [ROOM NUMBER] and caulk and flooring around the toilet were stain free on 09/23/25. These failures could place the residents at risk for diminished quality of life.Findings included:During an observation and interview on 09/22/25 at 11:07 a.m. in the bathroom for room [ROOM NUMBER], there were numerous…

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 disease and infection for 1 of 5 residents (Resident #16) reviewed for infection control. CNA W and CNA CD did not complete hand hygiene after changing gloves and when going from dirty to clean, while providing incontinent care for Resident #16. This deficient practice could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #16's face sheet, dated 09/24/2025, revealed a [AGE] year-old female with an admission date of 11/09/2020 with diagnoses which included: diabetes mellitus type 2, severe obesity, difficulty in walking, and lack of coordination. Record review of Resident #16's quarterly MDS assessment, dated 09/19/2025, revealed Resident #16 had a BIMS score of 12, which indicated…

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 comprehensive plan of care was developed within 7 days after completion of the comprehensive assessment and revised to reflect the current status for 3 of 5 residents (Resident #2, Resident #3, and Resident #4) reviewed for care plan timing The facility did not develop a comprehensive care plan within 7 days of the completion of the comprehensive assessment for Residents #2, #3, and #4. This failure could place residents at risk of not receiving appropriate care and services timely.Findings included: Record review of Resident #2's face sheet dated 08/28/25 indicated he was a [AGE] year old male, admitted to the facility on [DATE], and his diagnoses included C1-C4 complete quadriplegia (paralysis that affects all four limbs), diabetes (high blood sugar), hyperlipemia (high levels of fats in the blood), chronic embolism and deep vein thrombosis of bilateral lower extremities (presence of a blood clot), neuromuscular dysfunction of bladder…

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 received an accurate assessment, reflective of the resident's status for 1 of 5 residents (Resident #2) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #2's active diagnoses. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of Resident #2's face sheet dated 08/28/25 indicated he was a [AGE] year old male, admitted to the facility on [DATE], and his diagnoses included C1-C4 complete quadriplegia (paralysis that affects all four limbs), diabetes (high blood sugar), hyperlipemia (high levels of fats in the blood), chronic embolism and deep vein thrombosis of bilateral lower extremities (presence of a blood clot), neuromuscular dysfunction of bladder (problem with brain , nerves or spinal cord causes loss of bladder control), hypertension…

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 1 of 4 residents (Residents #1) reviewed for infection control. The facility failed to ensure LVN A utilized enhanced barrier precautions with wearing a gown while providing wound care to Resident #1. These failures could place residents at risk for cross contamination and the spread of infection.Findings included: Record review of a face sheet dated 08/28/25 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic subdural hemorrhage (a type of bleeding near your brain that can happen after a head injury) without loss of consciousness, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit (problem with communication that results from…

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, functional, sanitary, and comfortable environment for the residents in rooms 217 through 224 (8 rooms for this hallway) and 1 resident of 8 residents (Resident #1) that were observed for physical environment. The facility failed to ensure the hallway and the attached rooms 217 through 224 were free of odors. The facility failed to ensure a dresser in Resident #1's room was in good repair. These failures could place the residents at risk for diminished quality of life. Findings included: 1. An observation on 07/08/25 from 8:20 AM to 9:26 AM revealed a foul odor starting from the beginning of the hallway extending to the end of the hallway. As the State Surveyor walked through the hallway it was strongest of the odor in front of room [ROOM NUMBER]. The odor smelled of urine, feces, and body odor all combined making it hard to breath as the State Surveyor walked the length of the hallway (rooms 217 - 224). An observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program, so the facility was free of pests and rodents for five (Residents #1, # 2, #3, #4, and #5) of fifty-five residents reviewed for effective pest control. The facility failed to ensure Resident #1, # 2, #3, #4, and #5's rooms were free of pests. These failures could place residents at risk of exposure to bugs and bug bites. Findings included: An observation and interview on 07/08/25 at 8:33 AM revealed two cockroaches scattered from the center of the room to the wall, as the State Surveyor entered Resident #1's room. Resident #1 stated her roommate was gross and gets poop everywhere. She has food and soda that attracts the roaches. An observation on 07/08/25 at 8:48 AM revealed five dead cockroaches and one live cockroach in Resident #2 and Resident #3's room. The residents were not in the room at the time. An observation and interview on 07/08/25 at 9:27 AM revealed a small cockroach ran across…

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 prompt efforts were made to resolve grievances for 1 of 5 (Resident #1) residents reviewed for grievances. The facility did not thoroughly investigate or take prompt action to resolve grievances voiced by Resident #1 that she did not want CNA A or CNA B enter her room or provide care. This failure could place residents at risk of unresolved grievances and decreased quality of life. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included dementia (loss of cognitive functioning), anxiety (intense, excessive and persistent worry and fear about everyday situations), schizophrenia (serious mental health condition that affects how people think, feel and behave), unspecified mood disorder (complex mental health condition), paranoid personality disorder (mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate…

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

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week reviewed for RN coverage for 24 of 45 days reviewed for nursing services. (10/7/24, 10/9/24, 10/10/24, 10/11/24,10/14/24, 10/15/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/28/24, 10/29/24, 10/30/24, 10/31/24, 11/1/24, 11/2/24, 11/3/24, 10/19/24, 10/20/24, 11/9/24, 11/10/24, 11/16/24 and 11/17/24) The facility did not have 8 consecutive hours a day for 7 days a week of RN coverage for 24 days. This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of a Calculated Time by Entry form from 10/6/24 through 11/19/24 indicating RN hours worked indicated no RN hours for 10/7/24, 10/9/24, 10/10/24, 10/11/24,10/14/24, 10/15/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/28/24, 10/29/24, 10/30/24, 10/31/24, 11/1/24, 11/2/24, 11/3/24. The report indicated less than 8 hours a day worked on 10/19/24 - 4.90 hours, 10/20/24 - 5.18 hours, 11/9/24 -…

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.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 2 of 3 quarters reviewed for administration (Quarter 2 2024 (January 1-March 31), Quarter 3 2024 (April 1-June 30), Quarter 4 2023 (July1- September 30) 1. The facility failed to submit staffing information to CMS for FY Quarter 2 2024 (January 1-March 31); and 2. The facility failed to submit staffing information to CMS for FY Quarter 3 2024 (April 1-June 30). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record Review of the facility's Civil Rights form (3761) (Texas Health and Human Services form that list the facility staff to ensure the facility is not violating the Civil…

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 all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove, 1 of 2 walk-in coolers, 1 of 1 milk box in the kitchen; and 1 of 15 resident rooms on 1 of 2 Halls (long part of Hall 200) reviewed for essential equipment. * The facility failed to ensure the gas stove was in safe operating condition. Two burners on the back of the stove and 1 burner on the front of the stove would not ignite when the knobs were turned. The side of the griddle next to the burners had black buildup. * The facility failed to maintain the walk-in freezer. The walk-in freezer had a door gasket that was loose and hanging. * The facility failed to maintain the milk box. The milk box had a loose gasket with mildew on it. * The facility failed to ensure room [ROOM NUMBER]'s electric bed was in safe operating condition. The electrical cord plugged into the wall socket was spliced together. These failures could place the…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. The facility did not ensure baking sheets and baking pans did not have dark colored build up on the outside and inside. The facility did not ensure the foods labeled were disposed of after the use by date. The facility did not ensure foods removed from their original package were labeled with the required information of what the food was in the container and the use by date or date it was placed in the container. The facility did not ensure red bucket of sanitizing solution to clean surfaces in the kitchen had the right amount of cleaning solution. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observation and interview on 11/18/24 of the kitchen on initial tour indicated: * at 08:22 a.m. there were -4 large baking sheets with dark colored buildup on the inside corners and all along the outside edges; they were stacked together -3 large…

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 and sanitary environment for 1 of 2 Halls (Hall 200 long) and the dining room reviewed for physical environment. The facility failed to maintain the 200 long hall. Door frames of resident's rooms were not intact. Floor tiles were discolored tiles. There was a buildup of glue, paint, and debris behind all the doors to resident's rooms. The facility failed to maintain the exit corridor from the long hall 200 to the smoking area. There were 6 missing floor tiles that each measured 12 inch by 12 inch. The facility failed to maintain the main dining room floor. The tile in the main dining room along the back wall on the floor had a 2-inch-wide buildup of old paint and dried glue. There was one missing tile near the door. The facility failed to maintain an unlocked closet closet on the 200 long hall that was labeled oxygen on the door. The closet was empty and the walls were covered with black fuzzy substance in clusters on all…

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 store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 (Resident #28) of 13 residents reviewed for pharmacy services. The facility failed to ensure Resident #28's nystatin powder (prescription powder treats fungus or yeast) was not left on her nightside table and within the eyesight of the nurse This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. Findings included: Record review of Resident #28's face sheet dated 11/20/24 indicated Resident #28 was admitted on [DATE] was [AGE] years old female with diagnoses of severe obesity and diabetes (too much sugar in the blood). Record review of Resident #28's MDS assessment dated [DATE] indicated Resident #28's cognition was intact and had diabetes. Review of Resident #28's physician orders 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 interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the State Survey Agency, for 4 of 15 residents (Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for reporting allegations of abuse. 1. The facility failed to report an allegation of abuse to the State Agency within 2 hours when it was reported on 01/25/2024 that Resident #4 cursed at and hit Resident #5. 2. The facility failed to report an allegation of abuse to the State Agency within 2 hours when it was reported on 08/27/2024 that Resident #6 hit Resident #7. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 01/23/2024 indicated Resident #4 was [AGE] years old male,, initially admitted to facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the PASRR comprehensive service plan was implemented for 1 of 2 residents reviewed for PASRR assessments. (Closed Record #8) The facility did not provide and arrange for specialized physical therapy, occupational therapy, and speech therapy services for Closed Record #8 as recommended and agreed upon by the IDT within the time frame set by PASRR. This failure could place residents who are PASRR positive at risk of not receiving the necessary services that would enhance their quality of life. Findings included: Record review of a face sheet dated 10/22/24 indicated Closed Record #8 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression and bipolar disorder), cerebral palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development, often before birth), dysphagia (difficulty…

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

Based on interviews and record review the facility failed to ensure they had a full time DON and failed to ensure there was an RN for 8 consecutive hours 7 days a week for 1 of 1 facility reviewed for DON and RN coverage. The facility did not have a full-time DON as of 08/16/24. The facility did not have RN coverage for 8 consecutive hours on from 09/16/24 through 09/20/24, 09/23/24 through 09/25/24, 09/27/24, and 09/30/24. These failures could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of staff hours from 08/01/24 through 09/30/24 indicated there was no DON in the facility from 08/16/24 through 09/30/24. Record review of staff hours from 08/01/24 through 09/30/24 indicated there was no RN coverage on 09/16/24, 09/17/24, 09/18/24, 09/19/24, 09/20/24, 09/23/24, 09/24/24, 09/25/24, 09/26/24, 09/27/24, and 09/30/24. During an interview on 09/25/24 at 9:00 a.m., the Administrator said the facility did not have a current DON, however she was in the process of hiring a DON. She said there was no DON in the facility…

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 PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 3 of 3 residents (Resident #s 1, 2, and 3) reviewed for pharmacy services. 1. The facility failed to ensure Residents #1, #2, and #3 had a stop date for PRN anti-anxiety and antipsychotic medications. 2. The facility failed to monitor Resident #1's behaviors for his prescribed Ativan during the months of August and [DATE]. These failures could place residents at risk of receiving unnecessary psychotropic medications and of not receiving the intended therapeutic benefits of their psychotropic medications. The findings included: Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old,…

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 were reported, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the State Survey Agency, for 2 of 6 residents (Resident #Unnamed and Resident #4) reviewed for reporting allegations of abuse. The facility failed to report an allegation of sexual abuse to the State Agency when it was reported on 08/02/24 that Resident #1 touched Resident #Unnamed breasts. The facility failed to report an allegation of sexual abuse to the State Agency when it was reported on 08/25/24 that Resident #1 touched Resident #4's breast. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to facility on 03/07/24 and readmitted to facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain acceptable parameters, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise and the facility failed to offer a therapeutic diet when there was a nutritional problem and the healthcare provider ordered a therapeutic diet for 5 of 5 residents (Resident #s 1, 2, 3, 4, and 5) reviewed for weight loss and nutrition. The facility failed to ensure systems were in place to monitor for weight changes. 1. The facility failed to ensure Resident #1 did not sustain a significant weight loss of 47 lbs./20% weight loss X 1 month, 51 lbs./22% weight loss X 3 months, and 49 lbs./21% weight loss X 6 months. 2. The facility failed to ensure Resident #2 did not sustain significant weight loss of 7.5% change (comparison weight 03/14/24, 117.6 lbs., -15.3%, -18 lbs.) 3. The facility failed to ensure Resident #3 did…

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 1 of 7 residents (Resident #6) reviewed for infection control. 1. The facility failed to ensure Resident #6's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order. 2. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene between glove changes during wound care, after picking up a packaged mint off the floor, and before and after entering and exiting Resident #6's room. These failures could place residents at risk for infections. Findings included: 1. Record review of the face sheet dated 7/1/24 indicated 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 interview 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 met professional standards of quality care and that was developed within 48 hours of a resident's admission for 1 of 7 residents (Resident #6) reviewed for baseline care plans. The facility failed to ensure Resident #6 had a baseline care plan completed within 48 hours of his admission on [DATE]. This failure could place newly admitted residents at risk of receiving inadequate care and services. Findings included: 1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes (high blood sugar), Charcot's joint syndrome (a rare complication of 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 ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 7 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's care plan was not closed on 12/19/23 and was being reviewed and revised quarterly. This failure could place residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of the face sheet dated 6/28/24 indicated Resident #9 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including dementia, blindness, heart disease, schizoaffective disorder (a mental condition including schizophrenia and mood disorder symptoms), hypertension (elevated blood pressure), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 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 observation, interview and record review the facility failed to ensure a resident with limited range of mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for 1 of 5 residents (Resident #1) reviewed for range of motion. The facility failed to assess and provide hand rolls and/or positioning devices in Resident #1's right hand to prevent future decline in ROM. This failure could place resident at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings include: Record review of Resident #1's face sheet, dated 06/20/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included epilepsy (seizures), falls, mood disorder (intense shifts in mood), intellectual disabilities, GERD (reflux disease), functional quadriplegia (complete immobility 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 permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 6 residents (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was readmitted to the facility, after being treated at a behavior hospital. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. Findings included: Record review face sheet dated 6/3/24 indicated Resident #1 was readmitted on [DATE] and her original admission date was 07/01/22. She was [AGE] years old with diagnoses included schizophrenia (a disorder that affects a person ability to think, feel and behave clearly), persistent mood disorder (chronic…

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 follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 of 6 residents (Resident #1) reviewed for discharge requirements. The facility failed to follow the written policy to ensure Resident #1 was readmitted to the facility, after being treated at the Behavior Hospital and after being treated at Hospital C. This failure could affect discharged residents and placed residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. Findings included: Record review of the policy titled Transfer or Discharge Notice dated 12/20/12 indicated Our facility shall provide a resident and /or resident's representative with a 30-day written notice of an impending discharge notice . Record review face sheet dated 6/3/24 indicated Resident #1 was readmitted on [DATE] and her original admission date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve resident grievances for 1 of 22 residents (Resident #2) reviewed for grievances. There was no grievance available or evidence of resolution when Resident #2 reported to CMA H she did not want CNA M to come in her room or provide her care. This failure could place all residents at risk of unresolved grievances and decreased quality of life. Findings included: Record review of Resident #2's face sheet dated 05/22/24 indicated she was [AGE] years old, was admitted [DATE], and her diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and schizophrenia (serious mental health condition that affects how people think, feel and behave). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others and she 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.

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 objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to develop and implement a care plan for Resident #1's aggressive behaviors toward others. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities)…

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 services provided or arranged by the facility as outlined by the comprehensive care plan meets professional standards of quality for 3 of 6 residents (Resident #s 1, 2, and 3) reviewed for skin assessments. The facility failed to ensure Residents #1, #2, and #3 received a weekly skin assessment. This failure could place the resident at increased risk of not having their individual needs met and of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions. Findings included: Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, 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 residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 12 residents (Resident #1) reviewed for ADLS. The facility failed to ensure Resident #1's fingernails were trimmed. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of physical, mental and psycho-social well-being. Findings included: Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and cognitive communication deficit. 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 interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 7 residents (Residents #1, #2, and #3) reviewed for comprehensive person-centered care plans. 1. Resident #1's comprehensive person-centered care plan was not updated to reflect behavior of physical aggression toward another resident. 2. Resident #2's comprehensive person-centered care plan was not updated to reflect an altercation when another resident had been physically aggressive with her. 3. Resident #3's comprehensive person-centered care plan was not updated to reflect when another resident had been physically aggressive with her. These failures could place residents at risk for not receiving the necessary care and services they required. The findings were: 1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure all allegations of abuse or neglect were reported to the Administrator immediately. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's Abuse and Neglect policy dated June 2023 indicated .All allegations and/or suspicions of abuse/neglect must be immediately reported to the facility Administrator or designee in the absence of the administrator. The Administrator is the Abuse Coordinator. the allegation of abuse must be reported to HHSC immediately and not later than 2 hours after receiving the allegation of abuse. Record review of a face sheet indicated Resident #1 was a [AGE] year-old admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after Resident #1 threatened if she had a knife she would stab herself and someone else in the heart. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet indicated Resident #1 was 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 observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 4 of 7 residents (Residents #1, #2, #3, and #4) reviewed for personal privacy in that: CNA A failed to provide privacy for Resident #1 during bed mobility and personal care while Resident #2 was in the room. The facility failed to provide privacy for Residents #3 and #4. The room did not have a privacy curtain to allow for privacy when the residents were in the room. These failures could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care. Findings included: 1. Record review of Resident #1's electronic face sheet, undated, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) with left 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 observation and interview, the facility failed to equip each room to assure full visual privacy for each resident for 2 (Rooms 221 A & B and room [ROOM NUMBER] A & B) of 26 dual rooms reviewed for privacy. The facility failed to provide curtains to ensure residents' privacy in 2 dual occupancy rooms throughout the facility. This failure could place residents at risk of decreased self-worth by being exposed during resident care. Findings included: During an observation and interview on 10/12/2023 at 2:30 pm, resident in room [ROOM NUMBER]A was sitting in his wheelchair in his room. There was not a privacy curtain between resident in room [ROOM NUMBER]A and resident in room [ROOM NUMBER]B. Resident in room [ROOM NUMBER]A bed (nearest to the door). Resident in room [ROOM NUMBER]A bed said he wished he had a privacy curtain between the beds in the room so he could have privacy when he wanted it. Resident in room [ROOM NUMBER]A bed said he had been in this room for approximately 1 month and had never had a…

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