Benbrook Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) of eight residents observed for supervision. The facility failed to ensure Resident #1, who required 2 staff members for transfers by a mechanical lift, was not transferred by 1 staff member. This failure could place residents at risk of being in an unsafe environment and at risk of accidents and/or injury. Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) of eight residents observed for supervision. The facility failed to ensure Resident #1, who required 2 staff members for transfers by a mechanical lift, was not transferred by 1 staff member. This failure could place residents at risk of being in an unsafe environment and at risk of accidents and/or injury. Findings included: Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 2 (Resident #1's room and Resident #3's room) of 5 residents room reviewed for pestThe facility did not ensure Resident #3's room was free of roaches and Resident #1's room was free of gnats. This failure could place residents at risk for uncomfortable environment.Findings included: Record review of Resident #1's face sheet dated 01/21/26 reflected, Resident#1 was admitted to the facility on [DATE]. Resident #1 was diagnosed with but not limited to, Cerebral palsy (a group on conditions that affect movement and posture), unspecified, major depressive disorder (Mod disorder that significantly impacts daily life) recurrent, unspecified and anxiety disorder (mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation).Record review of Resident #1 MDS, dated [DATE] reflected Resident #1 had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received food that was appetizing, appealing, and proper temperature prior to serving.The facility failed to ensure milk was at a safe temperature before serving. The facility failed to ensure the dinner roll item was appealing and appetizing food item. The facility failed to ensure the baked potatoes were appealing texture. This failure could result in residents' not being provided food that is nutritious and appealing, resulting in a decreased quality of life.Findings include: Record review of Resident #16's face sheet dated 09/11/2025, revealed a [AGE] year-old woman admitted on [DATE] from a psychiatric hospital. She was admitted with primary diagnoses chronic obstructive pulmonary disease and other pertinent diagnoses including post-traumatic stress disorder, anxiety disorder, adult financial abuse (confirmed, subsequent encounter), adult sexual abuse (confirmed, subsequent encounter), adult physical abuse…

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 store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. The facility failed to ensure the stand-by freezer food items were dated, labeled, and secured.2. The facility failed to ensure the stand-by refrigerator food items were dated, labeled, and secured.3. The facility failed to ensure the dry storage food items were dated, labeled, and procured.4. The facility failed to ensure that canned good food items were free of dents.5. The facility failed to ensure that held food items were covered prior to serving.These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included: Observation on 09/09/2025 at 7:45AM upon entrance to the kitchen revealed an uncovered metal tin of butter with a pastry brush inside the tin, sitting on the stove top griddle.Observation on 09/09/2025 at 7:46AM of the standby freezer revealed:- An unsealed bag of frozen pizza dated 9-3-25 and with no use by date.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide a clean, functional, homelike environment for 2 of 4 shower rooms, 4 of 10 Residents (Resident 10, 53, 59, 78) reviewed for sanitary, functional, and homelike environment, as evidenced by: 1. Residents #10 and #53 had a broken toilet on 9-10-2025, causing the odor of human waste for over a week, forcing the residents to go to the shower room to use a toilet. When the shower room was in use, the residents had to wait to use a toilet. 2. The facility failed to maintain functional plumbing in the 100-Hall shower room, in which the water did not get hotter than 76.5 degrees Fahrenheit. 3. The facility failed to maintain functional plumbing in the 200 Hall Shower room, which had broken shower faucets, and the water could only be adjusted in the back by turning the main shower valves hot and cold. 4. The facility failed to repair a plumbing leak in 2 resident rooms, rooms [ROOM NUMBERS]. These failures could place residents at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: 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 for 2 of 8 rooms (room [ROOM NUMBER] and 201) and for 4 of 8 Residents (Resident #12, # 22, 59 and #78) reviewed for refrigerators in the rooms. 1.Facility failed to monitor refrigerator temperature on 09/05/25, 09/06/25, 09/07/25, 09/08/25, and 09/09/25 in room [ROOM NUMBER] and room [ROOM NUMBER] 2.Facility failed to monitor and did not put thermometers or maintain temperature logs in Resident #59's and Resident #78's refrigerators. 3.Facility failed to monitor temperature and/or maintain temperature logs for Resident #12's and Resident #22's refrigerators. These failures could affect residents by placing them at risk for food-borne illnesses. Finding included: 1.Observation in room [ROOM NUMBER] on 09/09/25 at 08:46 AM revealed two personal refrigerators in the room. The…

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

Based on observation, interview and record review, the facility must properly dispose of garbage and rubbish in accordance with current state laws for 1 of 1 dumpster reviewed for garbage disposal.The facility failed to ensure all garbage items were placed into the dumpster and the dumpster doors were closed and secured.This failure could place residents at risk of infection and result in a pest infestation from improperly disposed garbage.Findings included: Observation on 09/09/2025 at 8:10AM of the facility's dumpster and dumpster area revealed a commercial-size dumpster 1/2 full of garbage. The left- and right-side doors were open. On the ground of the left side of the dumpster were 4 full plastic garbage bags, 2 partially filled plastic garbage bags, and 2 empty cardboard boxes. Laying on the ground in the dumpster area were 2 mattresses. Interview on 09/10/2025 at 3:34PM with the ADM revealed all staff use the dumpster and expected all doors on the dumpster to be closed. During an interview on 09/11/2025 at 8:00PM with the ADM, he stated generally all staff are responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from verbal abuse for 1 of 4 residents (Resident #49) reviewed for abuse.The facility failed to ensure Resident #49 was free from verbal abuse by Resident #87 on 8/29/25 and 9/6/25. This could place residents at risk of abuse and psychosocial harm. Findings included:Record review of Resident #49's admission record, dated 09/10/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included bipolar disorder (serious mental illness that causes mood swings, changes in energy, thinking, behavior, and sleep), anxiety disorder, and unspecified Intellectual Disabilities (limitations on intelligence, learning and everyday abilities). Record review of Resident #49's Annual MDS assessment, dated 06/26/2025, revealed a BIMS score of 13, indicating intact cognition. Record review of Resident #49's nursing progress notes, dated 09/06/2025, written by LVN M, 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, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures, for 2 of 4 residents (Resident #49) reviewed for abuse. The facility failed to ensure a resident-to-resident altercation that occurred on 08/29/25 was reported to the State Survey Agency. This could place residents at risk of abuse. Findings included:Record review of Resident #49's admission record, 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 observation, interview and record review, the facility failed to complete and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, therapeutic, and psychosocial needs in order to attain or maintain the resident's highest practicable well-being for one resident (Resident #16) of seven residents reviewed for care plans. The facility failed to complete care plans addressing Resident #16's history of abuse and PTSD. This failure could affect residents by placing them at risk for not receiving care to maintain and/or reach their highest practicable mental and psychosocial well-being. Findings included:Record review of Resident #16's face sheet dated 09/11/2025, revealed a [AGE] year-old woman admitted on [DATE] from a psychiatric hospital. She was admitted with primary diagnoses chronic obstructive pulmonary disease and other pertinent diagnoses including post-traumatic stress disorder (mental health condition that can develop after experiencing or…

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 residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #83) of one resident reviewed for quality of care. The facility failed to monitor Resident #83's blood glucose levels before administering insulin. This failure could place residents at risk for not receiving appropriate care and treatment and decreased quality of life.Findings included: Record review of Resident #83's face sheet dated 09/11/2025 revealed a [AGE] year old female, admitted on [DATE] with primary diagnosis of fibromyalgia and other pertinent admitting diagnoses including type 2 diabetes mellitus with diabetic neuropathy, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, pure hypercholesterolemia, major depressive disorder, generalized anxiety disorder, heart failure, and hypertension. Record review of Resident #83's 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 Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent complications of enteral feeding for 1 of 1 resident (Resident #8) observed for medication administration via gastrostomy tube. 1.LVN D did not raise the head of bed during medication administration and water flush via G-tube for Resident # 8. Resident #8 was laid flat on his back. 2. LVN D did not clean the syringe and plunger before placing it in the sealed bag after administering medications via G-tube to Resident #8. 3. Facility failed to obtain orders to elevate the head of bed to at least 30-45 degrees up for Resident #8 who received continuous feedings via G-tube. 4. Facility failed to care plan to elevate the head of bed to at least 30-45 degrees up for Resident #8 who received continuous feedings via G-tube. These failures could place residents at risk for aspiration and interactions between the formula and various medications.…

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 Number of residents sampled: Number of residents cited: Based on observations, interviews, 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 medication cart for 1 of 3 medication carts (Med Cart B) reviewed for storage of medication. 1.LVN E failed to ensure Med Cart B was kept locked and under direct observation where residents and unauthorized staff could access it outside room [ROOM NUMBER]. These failures could give access to unauthorized persons, as well as medications may not be maintained at their best therapeutic level. Findings included: 1. Observation and interview on 09/10/25 from 08:20 AM to 08:27 AM, revealed Med Cart B outside room [ROOM NUMBER]. Med Cart B was unlocked and unattended with the lock mechanism out (indicating it was unlocked). The door to room [ROOM NUMBER] was open and staff was not in…

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

Based on interview and record review, the facility failed to ensure required in-service training for nurse aides was completed for 2 of 5 CNA's (CNA K and CNA L) reviewed for training. The facility failed to ensure nurse aides received no less than 12 hours of training annually.This failure could place residents at risk of abuse, neglect, and exploitation and receiving poor quality of care by untrained staff. Findings included:Record review of personnel files for CNA K revealed a hire date of 03/20/2014. Record review of personnel files for CNA L revealed a hire date of 08/30/2024. Review of in-services revealed CNA K and CNA L did not have the required 12 hours of annual training. Interview on 09/11/2025 at 5:57 pm, the Administrator stated they could not provide the required training for all the CNAs. He stated they were going to change their training program where everyone would complete the required training on their anniversary date. He stated they will still have monthly and annual in-services. He stated the risk to residents being cared for by untrained staff was failure 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, in response to allegations of abuse or neglect, ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for reporting of abuse. The facility failed to report to the State Survey Agency the elopement of Resident #1 during July of 2025. This failure could place residents at risk for unresolved or future abuse or neglect.Findings included: Review of Resident #1's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including 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, in response to allegations of abuse or neglect, have evidence that all alleged violations were thoroughly investigated, prevent further potential abuse and neglect while the investigation was in progress, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and take appropriate corrective action if the alleged violation was verified one (Resident #1) of five residents reviewed for reporting of abuse. The facility failed to investigate and report to the State Survey Agency the results of the investigation of the elopement of Resident #1 during July of 2025. This failure could place residents at risk for unresolved or future abuse or neglect.Findings included: Review of Resident #1's Face Sheet reflected she was a [AGE] year-old female admitted to the 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.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for two of three shower rooms reviewed for environmental concerns. 1. The facility failed to ensure the toilet in the 200 Hall shower room was operational and did not contain a dried brown substance (appeared to be feces) which was covered by a clear plastic trash bag. 2. The facility failed to ensure the 200 Hall shower room did not have a hole in the wall of which exposed the plumbing. 3. The facility failed to ensure the toilet in the 100 Hall shower room was operational which covered by a clear plastic trash bag. These failures could place residents at risk of living in an unclean, uncomfortable and unhomelike environment. Findings include: In an observation on 6/03/25 at 10:05 AM, revealed a large (approximately 2-foot by 1.5-foot) hole in the wall behind the shower which had exposed plumbing pipes. The toilet in the shower room was covered by a clear trash bag.…

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

Based on observation, interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care and nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments and described in the plan of care for two of two medication aides (MA E and MA C) and two of three nurses (LVN A and LVN D ) reviewed for competent nursing staff . The facility failed to ensure staff knew how to identify an overfilled sharps container. This failure could place residents at risk of laceration or stick by sharps . The findings include: In an observation on 6/03/25 at 10:05 AM, revealed the sharps container hanging on the wall of the shower room in the 200 Hall was noted as overfilled beyond the manufacturer fill line and was still in use with the receptacle in the open position. In an interview on 6/03/25 at 10:10 AM, LVN A reported she had been the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 one Resident (Resident #1) of seven residents reviewed for infection control. -The facility failed to follow the physician's order for contact isolation for Resident #2, who was diagnosed with ESBL, when there were no effective interventions in place to keep the resident isolated in her room and prevent the spread of the infection. This failure placed residents at risk for the spread of infections and decreased quality of life. Findings include: Record review of Resident 1's face sheet, dated 5/30/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: mixed anxiety and depressed mood (mood disorder), heart disease with presence…

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 each resident received adequate supervision and assistance devices to prevent accidents for one resident (Resident #2) of five reviewed for accidents. -The facility failed to ensure Resident #2 was provided with adequate supervision to prevent the misuse of a smoking product that contained THCA. This failure could place residents at risk for accidents that could lead to serious injury or harm. Findings include: Record review of Resident 2's face sheet, dated 5/29/25, reflected the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included: COPD (lung disease), bipolar disorder (mood disorder), hypertension (high blood pressure), generalized anxiety disorder (mood disorder), paroxysmal atrial fibrillation (heart condition) with presence of cardiac pacemaker (device that helps regulate an irregular heartbeat). Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 5 residents (Resident #1) reviewed for shower documentation. The facility failed to ensure documentation reflected Resident #1 received showers as scheduled and desired. This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life. Findings Included: Record review of Resident #1's Face Sheet dated 4-24-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Sequelae (a condition which is the consequence of a previous disease or injury) following nontraumatic subarachnoid hemorrhage (bleeding into the space between the brain and the thin tissues that cover it causing long-term or permanent…

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 a safe, clean, comfortable, and homelike environment was provided for 3 of 4 (Resident #1, #2, and #3) shared resident bathrooms and for 1 of 3 (Resident #10) residents rooms reviewed for environmental conditions. 1. The shared bathroom for Residents #1, #2, and #3 had dark brown dried substances on the toilet, the floor, and the wall. 2. Resident #10's room featured a blanket covering the air condition window unit and a towel placed on the base of the windowsill. Additionally, there were two openings in the wall behind the unoccupied bed B in the same room. These failures could affect residents and place them at risk of feeling uncomfortable as a result of living in an unclean and unsanitary environment and living in a room that showed signs of poor maintenance. Findings included: Review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted on [DATE]. She had a BIMS score of three indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 4 of 4 Residents (Resident #6, Resident #7, and Resident #9) reviewed for smoking, and 1 of 1 Resident (Resident #4) reviewed for environment. The facility failed to ensure Residents #6, Resident #7, and Resident #9 were provided supervision while smoking. The facility failed to ensure Residents #6, Resident #7, and Resident #9 were accurately assessed for smoking. The facility failed to ensure Resident #9 was assessed for smoking per facility policy. The facility failed to ensure Resident #4 did not have an electric kettle in her room on the secure unit. These failures could place residents at risk of harm, injury, or accidents. Findings included: Record review of Resident #6's admission Record, dated [DATE], revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Encephalopathy…

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 right to be free from misappropriation of resident property for 1 of 1 (Resident #4) resident reviewed for misappropriation of property. The facility failed to ensure CNA B did not take Resident #4's debit card to buy the resident items and for CNA B's personal use. The noncompliance was identified as PNC. The noncompliance began on 11/20/2024 and ended on 12/04/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk exploitation and misappropriation of property. Findings included: Record review of Resident #4's admission Record, dated 12/9/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), major depressive disorder, and anxiety. Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 5 residents (Resident #5) reviewed for ADLs. The facility failed to ensure Resident #5's nails were trimmed, and beard shaved. These failures could place residents at risk of infection and a decreased quality of life. Findings included: Record review of Resident #5's admission Record, dated 03/12/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included osteoarthritis of knee, depression and anxiety. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 13, indicating intact cognition. Further review revealed Resident #5 required substantial/maximal assistance with showering and personal hygiene. Record review of ADL sheet, dated 02/11/25 through 03/12/25 revealed Resident #5 had showers on 02/14/25, 02/28/25, 03/04/25, and 03/08/25, 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 observations, interviews, and records review, the facility failed to ensure a resident did not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provided care and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers/injuries from developing for 1 (Resident #1) of 7 residents reviewed for pressure ulcers/injuries. 1.The facility failed to perform complete and accurate skin assessments for Resident #1, following LVN A's skin assessment on 11/06/24 which revealed moisture associated skin damage to Resident #1's buttocks. These failures placed residents with pressure wounds at an unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: Review of Resident #1's face sheet on 02/08/24 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Hemiplegia and hemiparesis following…

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 necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs. (Resident # 1). The facility failed to ensure staff provided Resident #1 with timely incontinence care before he ended up with feces on his hands, fingers, and hip. This failure could place residents who need assistance from staff for toileting at risk for embarrassment, rashes, infections, discomfort, and skin break down. Findings included: Record review of a face sheet dated 01/28/2025 indicated Resident #1 was [AGE] years old, readmitted to facility on 05/31/2024 with an initial admission on [DATE]. Resident #1 resides on the Memory Care Unit. Resident's diagnoses included Unspecified Dementia severe, with other behavioral disturbance (patient who exhibits significant behavioral issues beyond the typical cognitive decline, such as agitation, aggression, wandering, or…

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 resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for one (Resident #1) of 3 residents reviewed for resident call system. The facility failed to ensure Resident # 1's call light system (in room system, outside the resident door, and nurse station) was working properly. This failure could place resident at risk for delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record Review of Resident #1's admission Record revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of spondylosis without myelopathy or radiculopathy (degenerative changes in the spine with conditions that involve compression or irritation of the spinal cord or spinal nerves ). Record Review of Resident #1's Care Plan dated 09/19/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #1) of nine residents reviewed for pharmacy services. The facility failed to order Resident #1's routine Oxycontin timely to prevent three missed doses, 5:00 AM and 5:00 PM on 09/26/2024 and 5:00 AM on 09/27/2024. This failure placed residents at risk of worsening and/or exacerbation of their pain and medical conditions. Findings included: Record review of Resident #1's Face Sheet dated 09/27/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses included: Chronic obstructive pulmonary disease (lung disease that causes restrictive airflow), anxiety disorder due to unknow psychological condition (a mental health condition that causes fear and dread), major depressive disorder (mental health condition impacting…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 8 residents (Residents #17 and #25) reviewed for Comprehensive Care Plans. The facility failed to complete a comprehensive care plan for Residents #17 and #25. This failure could place residents at risk of not receiving necessary care and services. Findings included: 1.Review of Resident #17's admission Record, dated August 08, 2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]/24 with diagnoses that included Unspecified Sequelae Of Unspecified Cerebrovascular Disease, Dysphagia, Oropharyngeal Phase, Unspecified Dementia, Unspecified Severity, With Agitation, Mild Neurocognitive Disorder Due To Known…

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, observation, and record review, the facility failed to use the services of a registered nurse for 8 consecutive hours 7 days a week for 2 of 4 quarters of 2024 (Fiscal Year Quarter 2 January 1-March 31, and Quarter 3 April 1-June 30) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 8 consecutive hours on weekends for: 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/2024, 01/21/2024, 01/27/2024, 01/28/2024, 02/03/2024, 02/04/2024, 02/10/2024, 02/11/2024, 02/17/2024, 02/18/2024, 02/24/2024, 02/25/2024, 03/02/2024, 03/03/2024, 03/09/2024, 03/10/2024, 03/16/2024, 03/17/2024, 04/06/2024, 04/07/2024, 04/08/2024, 04/13/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, 04/28/2024, 05/04/2024, 05/05/2024, 05/11/2024, and 05/12/2024. This failure could place residents at risk of lack of nursing oversight and higher level of care needed. Findings included: Record review of the CMS PBJ reports indicated Quarter 2 2024 (January 1-March 31) there were no consecutive 8 hours of RN coverage on weekends. Record review 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 interview, and record review the facility failed to recognize the resident had the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law and the facility must treat the decisions of a resident representative as the decisions of the resident for one (Resident #1) of three residents reviewed for resident rights. The facility failed to include Resident #1's RP when Resident #86 was asked to sign a disenrollment form in order to change her Medicare insurance. This failure could place residents at risk of not having their RP included to make informed decisions regarding their care resulting in delayed treatment or a decline in condition. Findings included: Review of Resident #86's admission Record dated 08/08/24, reflected she was an [AGE] year-old woman, admitted on [DATE], with diagnoses of Alzheimer's dementia and other dementia. Resident #86 was listed as her only contact. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 1 of 25 residents reviewed for accommodation of needs. The facility failed to ensure Resident #35's call light was within reach of the resident. This failure could affect residents who needed assistance and could result in their needs not being met. Findings included: Record review of Resident #35's face sheet dated 8-8-2024, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of fracture of the left wrist and hand and secondary diagnosis of Parkinson's disease, dementia, altered mental status, and gait and mobility abnormalities. Record review of Resident #35's MDS assessment dated [DATE], disclosed a BIMS score of 5 indicating a severe cognitive impairment. The assessment further indicated Resident #35 was totally dependent (helper does all the effort) putting his shoes on 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 interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident, for 1 of 8 residents (Residents #17) reviewed for baseline care plans. The facility failed to ensure Resident #17's baseline care plan was completed. This failure could affect newly admitted residents and place them at risk of not receiving appropriate interventions to meet their current needs and communication among nursing home staff to ensure their immediate care needs were met. The findings included: Review of the clinical care plans of Resident #17 on August 8, 2024, at 8:25 AM revealed that there was not a baseline care plan started or completed between June 28, 2024 and August 8, 2024. Review of Resident #17's admission Record, dated August 08, 2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Unspecified Sequelae Of Unspecified…

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

Based on observation, interview, and record review the facility failed to ensure the facility's only garbage storage dumpster, and surrounding enclosed area, was maintained in a sanitary condition to prevent the attraction, nesting, and accumulation of pests. The facility failed to ensure trash was not left outside of the dumpster on the ground. These failures could place residents at risk of contracting disease by attracting pests, disease carrying rodents, and having debris dangerous to residents. Findings included: During an observation on August 8, 2024 at 3:45 PM of the dumpster area, on the north side of the building, there was trash debris including but not limited to used latex gloves, glass shards, broken overbed rolling tray tables, oscillating floor fans, bariatric bedside commode, well used recliner chair, well used mattress, split open bag of landscape mulch, opened individual dose medication blister packets, and base of a wheelchair scale. In an interview on August 8, 2024, at 5:05PM with DM revealed that the dumpster area was the responsibility of the DM and 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 observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 6 residents (Residents #1, #2, #3) reviewed for effective pest control. The facility failed to maintain an effective pest control program to ensure the facility was free of flies and gnats for Resident #1, #2, and #3's rooms. This failure could place the residents at risk for an unsanitary environment. Findings included: Record review of Resident #1's face sheet dated 7-18-2024, showed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had a diagnosis of cerebral infarction (stroke), schizophrenia (a chronic mental disorder that affects how people think, feel, and behave by disrupting thought processes and perceptions), bipolar disorder (a serious mental illness that causes extreme mood swings, from mania to depression), and lack of coordination. Record review of Resident #1's quarterly MDS revealed a BIMS score of 9 which indicated being mildly cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment; for 1 of 6 residents (Resident #1) reviewed for environment. The facility failed to ensure Resident #1's floor was clean from a dried yellowish liquid substance which had the smell of urine. This failure could put residents at risk for unsanitary living conditions. Findings included: Record review of Resident #1's face sheet dated 7-18-2024, showed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses of cerebral infarction (stroke), schizophrenia (a chronic mental disorder that affects how people think, feel, and behave by disrupting thought processes and perceptions), bipolar disorder (a serious mental illness that causes extreme mood swings, from mania to depression), and lack of coordination. Record review of Resident #1's quarterly MDS revealed a BIMS score of 9 which indicated being mildly cognitively impaired, was wheelchair bound, 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 observations, interviews, and record review the facility failed to provide a safe, comfortable, and homelike environment for 2 (Resident #1 and Resident #2) of 6 residents reviewed for environment. The facility failed to provide the necessary housekeeping and maintenance services to ensure Resident's #1 and #2's door opened without resistance. This failure placed residents who resided in the facility at risk of for diminished quality of life. Findings included: Record Review of Resident #1's admission Record undated reflected; Resident #1 is a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1's principal diagnosis of Paraplegia. Observation on 01/23/2024 at 11:47 a.m. revealed Resident #1's door rubbed the floor when open causing the door to require pressure to open. Interview on 01/23/2024 at 11:47 a.m. with Resident #1 reflected he stated the door was hard to open when he was in his wheelchair. He stated he was scarred on an occasion when there was a fire evaluation and he…

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 maintain the residents right to be free from verbal abuse for one of five residents (Resident #3) reviewed for Abuse. The facility failed to prevent Certified Nursing Aide A from verbally abusing (cursing) Resident #1. This deficient practice could place residents at risk for decreased quality of life, depression, and psychosocial harm. Review of Resident #3's admission Record reflected a [AGE] year-old male with an admission date of 10/19/2023 with the following diagnoses; A primary diagnosis of polyneuropathy, depression, cellulitis of right lower limb. Review of Resident #3's Care Plan dated 11/04/2023 reflected: Resident #3 has a behavior problem (demanding, verbally aggressive and abusive with staff, sneaking alcohol into the facility, and attention-seeking behavior, false accusations) r/t OPIOID DEPENDENCE, drug-seeking behavior; If reasonable, discuss Resident's behavior. Explain/reinforce why behavior was inappropriate and/or unacceptable 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 ensure that in accordance with accepted professional standard and practices, medical records were complete, accurately documented and included a record of the resident's assessments for one (Resident #1) of five residents reviewed for clinical records accuracy. 1. The facility failed to document when Resident #1's PRN narcotic pain medication (Hydromorphone and Oxycodone) was administered on the MAR on numerous occasions from 10/19/23 through 11/15/23. The narcotic count sheet was being signed off on that the medication was being taken from the narcotic blister pack, but the MAR did not reflect it was given. 2. The facility nurses failed to assess and document Resident #1 for pain when he requested PRN pain medication of Hydromorphone and Oxycodone during 10/19/23 through 11/15/23 on his nursing MAR or in the nursing progress notes. The facility failure could place residents at risk of inaccurate pain assessments, inaccurate administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident has the right to be informed in advance, by the physician or other practitioner or other professional of the risks and benefits of proposed care, treatment and treatment alternatives for one (Resident #1) of five residents reviewed for consent of psychoactive medications. Resident #1 did not consent for the use of Cymbalta (antidepressant) when his Prozac was discontinued after admission to the facility without his knowledge or input. He unknowingly received Cymbalta and did not feel like it was helping with his depression. The failure could place residents prescribed antipsychotic medications at risk of receiving a medication without consent, which could cause duplicate therapy, sedation, side-effects and uncomfortable emotional changes. Findings included: Record review of Resident #1's Face Sheet, dated 11/16/23, reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included…

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

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 6 residents (Resident #1, Resident #2, and Resident #3) observed for environment. The facility failed to: - fix the light fixture above the sink in Resident #1's room - fix the light fixture in the bathroom between Resident #1 and Resident #2's room. -fix the light fixture above the sink and the footboard in Resident #3's room. This failure could place residents at risk for injury and decreased quality of life. Findings included: Interview and observation on 08/23/2023 at 10:36 a.m., Resident #1 stated the light over the sink and in the bathroom does not work and he told staff last week. Observation in Resident #1's room revealed the light switch was in the on position, but the light was not working. Observation of the bathroom revealed the light did not turn on. Interview on 08/23/2023 at 11:46 a.m., Resident #1 stated he told the new maintenance man about the light and the maintenance man said he would fix it by Monday (08/21/2023).…

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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 24 residents (Resident #13) reviewed for resident call system. The facility failed to ensure Resident #13 had a working call light in her room. This failure could place residents at risk of not being able to get assistance when needed. Findings included: Record review of Resident #13 face sheet dated 06/22/2023 was a [AGE] year-old female admitted the facility on 09/27/2021 with diagnosis that include schizophrenia (Known to affect the ability to think), epilepsy (seizure disorder), osteoarthritis (joint disease), and type 2 diabetes. Record review of Resident #13 care plan dated for the month of June 2023 reflected the resident requires one-person assist for dressing, toileting, personal hygiene, oral hygiene, and moving between surfaces. Also indicated in her care…

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.