Town and Country Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, , the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 (#19) residents reviewed for quality of care in that: Resident #19's pacemaker maker, model, and additional information was not documented in his chart. This could affect residents with pacemakers and could result in residents not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The Findings were: Record review of Resident # 19's admission Record dated 5/21/2025 revealed he was admitted on [DATE], age was 83 no diagnosis description was documented for a cardiac pacemaker . Record review of Resident # 19's MDS assessment dated [DATE] revealed the presence of cardiac pacemaker, and he had a BIMS score of 8/15 (moderate cognitive impairment). Resident # 19's care plan dated 5/15/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for 1 (Resident #12) of 1 residents reviewed for quality of care. The facility failed to provide necessary arrangements to repair broken eyeglasses for Resident #12. This failure could lead to injury and/or decreased quality of life. Findings included: Record review of Resident #12's face sheet dated 5/20/2025 revealed an [AGE] year old male, admitted to the facility on [DATE]. Relevant diagnoses included unsteadiness on feet and muscle wasting and atrophy. Review of Resident #12's quarterly MDS assessment submitted 4/1/2025, reflected a BIMS score of 09, indicating moderately impaired cognition. Resident #12 was assessed as having vision impairment, and the resident required corrective lenses. Record of review of a progress note dated 5/2/2025, written by LSW, revealed the following: One of [Resident #12]'s ear pieces on his glasses is…

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, resident and staff interviews, and record reviews, the facility failed to ensure that residents' environment remained as free of accident hazards as possible for 1 of 4 residents (Resident #14) reviewed for quality of care. The facility failed to ensure Resident #14 had cushioned hip covers (hipsters) in place at all times. This failure could place residents at an increased risk for injury related to falls. The findings include: Record review of Resident #14's face sheet dated 5/22/25 revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE]. Diagnoses included Alzheimer's dementia (memory loss that affects learning and memory), COPD (Chronic Obstructive Pulmonary Disease, a progressive respiratory condition), Right femur (thigh bone) fracture, Right hip pain, dysphagia, abdominal aortic aneurysm, Bipolar Disorder (mood disorder ranging from depressive lows to manic highs), emphysema (a condition that causes breathlessness), Hypertension, Cardiomegaly, Polyosteoarthritis…

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

Based on observations, interviews, and record reviews, the facility failed to ensure Food safety requirements to prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 5 (Cook D) kitchen staff working that day, in that: Cook D's beard/mustache restraint was off and exposed his thin mustache, while taking food temperatures on the steam table. This failure could place residents at risk for food borne illness. The Findings were: Observation on 5/21/2025 at 11:47 PM with [NAME] D, during food temperature observations on the steam table, [NAME] D was wearing a beard guard that had fallen and exposed his thin mustache. During an interview on 5/21/2025 at 11:50 PM with [NAME] D, he stated he had the beard restraint on, and it had fallen and was not covering his thin mustache. During an interview on 5/21/2025 at 11:52 PM, the Dietician stated [NAME] C should have had the hair restraint over his mustache as well. During an interview on 5/22/2025 10:42 AM, the Dietary Manager stated staff should wear hair restraints to cover hair while in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to handle and transport linens so as to prevent the spread of infection and to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the developement and transmission of communicable diseases and infections for 3 of 7 residents (Residents #15, 75 and 139) reviewed for infection control. 1. The facility failed to ensure staff put soiled linen of Residents #15 and #75 into a container or bag prior to transporting. 2. The facility failed to ensure staff utilized PPE when providing high-contact care for Resident #139, whom was identified as requiring EBP. These failures could lead to the spread of infection and illness. Findings included: 1. Record review of Resident #15's face sheet dated 5/21/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with relevant diagnoses that included need for assistance with personal care and gastrostomy (surgical opening in the abdomen…

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's drug regimen was free of significant medication errors for 1 (Resident #2) of 5 residents reviewed for medications. The facility failed to ensure Resident #2 received his Metoprolol succinate extended-release oral tablet 50 mg one time a day for hypertension from 09/14/2025 to 09/24/2024 (total 11 days) as ordered by the physician. The noncompliance was identified as PNC on 05/02/2025. The PNC began on 09/14/2024 and ended on 09/27/2024. The facility had corrected the noncompliance before the survey began. The deficient practice placed the residents at risk of not receiving desired outcomes from medications that are not administered according to physician's orders. Findings Included: Record review of Resident #2's face sheet, dated 05/02/2025, revealed the resident was [AGE] years old male, originally admitted [DATE], and re-admitted to the facility on [DATE] with diagnosis of acute on chronic diastolic heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #1) of 5 residents reviewed for medication administration. The facility failed to ensure when the ADON was administered medications to Resident #1 on 04/30/2025 at 9:00 am in the common area, the ADON said the resident's medications loud when other residents was also in the common area. This failure could place residents at risk of resident identifiable and medical information being accessed by unauthorized persons. The findings were: Record review of Resident #1's face sheet, dated 05/02/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), malignant neoplasm of larynx (laryngeal cancer - cancer to a hollow tube in the middle of neck), dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #2) of 5 residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #2's blood pressure after re-checking the blood pressure when MAC notified LVN A the resident's blood pressure was 101/34 on 04/05/2025. This failure placed resident at risk for missed treatment and care which could result in decline in health and well-being. Findings included: Record review of Resident #2's face sheet, dated 05/02/2025, revealed the resident was a [AGE] year old male, originally admitted [DATE], and re-admitted to the facility on [DATE] with diagnoses of acute on chronic diastolic heart failure (heart not able to fill properly with blood during the diastolic phase, reducing the amount of blood pumped out to the body), type 2 diabetes mellitus (not control blood sugars),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #3) of 5 residents reviewed for infection control practices. The facility failed to ensure the ADON sanitized or washed her hands before administering medications to Resident #3. This deficient practice could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #1's face sheet, dated 05/02/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), malignant neoplasm of larynx (laryngeal cancer - cancer to a hollow tube in the middle of neck), dementia (group of thinking and social symptoms that interferes with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 out of 6 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1's wounds were measured weekly on (9) occasions. 2. The facility failed to ensure wound care treatments/dressings were provided to Resident #1 as ordered by the physician on (2) occasions. This deficient practice could place residents at risk for worsening wounds and/or infections. Findings included: 1. Record review of Resident #1's admission Record, dated 2/14/25, revealed the resident was re-admitted to the facility on [DATE] with diagnoses that included: Acquired absence of left leg below knee, Type 2 diabetes (chronic condition that affects the way the body processes blood sugar), Gangrene (death of tissue due to lack of blood flow or infection) , Atherosclerosis (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 ensure 1 of 1 (Resident #2) resident reviewed for pressure ulcers received necessary treatment and services, consistent with profession standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. 1. The facility failed to provide wound care treatments/dressing to Resident #2 as ordered by the physician on (22) occasions. 2. The facility failed to ensure LVN K followed physician orders during observed wound care for Resident #2's right lateral foot on 02/19/2025. 3. The facility failed to ensure LVN K documented a verbal order for wound care for the right lateral foot on 02/18/2025. This deficient practice could place residents at risk for worsening wounds and/or infections. Record review of Resident #2's admission Record, dated 2/18/25, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Contact Dermatitis (skin inflammation caused by friction or contact with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 4 of 6 residents (Resident #1, Resident #3, Resident #4, and Resident #6) reviewed for accuracy of records. 1. The facility failed to ensure Resident #1's treatments were documented per facility policy on (5) occasions. 2. The facility failed to ensure Resident #3's treatments were documented per facility policy on (17) occasions. 3. The facility failed to ensure Resident #4's treatments were documented per facility policy on (13) occasions. 4. The facility failed to ensure Resident #6's wound assessment was documented per facility policy. These deficient practices could place residents at risk for improper care due to inaccurate records. Findings included: 1. Record review of Resident #1's admission Record, dated 2/14/25, revealed the resident was re-admitted to the facility on [DATE] with diagnoses that 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 observations, interviews, and record reviews the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program as described at §483.80(a)(2). 18 of 28 nurses (LVN B, LVN D, RN G, RN H, LVN K, RN L, LVN P, LVN Q, LVN T, RN U, LVN V, LVN W, RN X, RN Y, LVN AA, LVN DD, LVN EE, and LVN FF) reviewed for hand hygiene training, 18 of 28 (LVN B, LVN F, RN G, RN H, RN J, LVN P, LVN Q, LVN T, RN U, LVN V, LVN W, RN Y, LVN AA, LVN BB, LVN DD, LVN EE, LVN FF, and ADON) reviewed for hand hygiene competency, and 28 of 28 (LVN B, LVN D, LVN F, RN G, RN H, LVN I, RN J, LVN K, RN L, LVN M, LVN P, LVN Q, LVN R, RN S, LVN T, RN U, LVN V, LVN W, RN X, RN Y, LVN Z, LVN AA, LVN BB, LVN CC, LVN DD, LVN EE, LVN FF, and ADON) reviewed for wound care training. 26 of 28 (LVN B, LVN D, LVN F, RN G, RN H, LVN I, RN J, LVN K, LVN P, LVN Q, LVN R, RN S, LVN T, RN U, LVN V, LVN W, RN X, RN Y, LVN Z, LVN AA, LVN BB, LVN CC, LVN DD, LVN EE, LVN FF, and ADON) reviewed for wound 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 out of 4 residents (Resident #6) reviewed for pain management. The facility failed to adequately assess and treat Resident #6's pain prior to or during wound care. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. Findings included: Record review of Resident #6's admission Record, dated 2/22/25, revealed the resident was re-admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (disease affecting memory and other important mental functions) , Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) , chronic pain, Dementia (group of thinking and social symptoms that…

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

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 6 medication carts (Treatment Cart) reviewed for medication storage. The facility failed to ensure the Treatment Cart was locked when unattended on (3) occasions. This failure could place residents at risk of medication misuse and drug diversion. Findings included: Observation on 2/22/25 beginning at 3:19 pm, RN L entered Resident #2's room, closed the door, and prepared to provide wound care leaving the treatment cart unlocked. Further observation revealed the treatment cart was unlocked when RN L opened Resident #2's room door after the treatment was completed. Observation revealed there were two CNAs on the hall when RN L exited the room. Further observation revealed RN L re-entered Resident #2's room, leaving the treatment cart unlocked. RN L was observed entering the resident's room to wash her hands, leaving the treatment cart unlocked. Further observation revealed a nurse at the far end of the hall preparing medications, a resident 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 observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #2 and Resident #3) reviewed for infection control. LVN K and RN L did not perform hand hygiene appropriately when providing wound care to Resident #2 and Resident #3. This deficient practice could affect all residents who require wound care and place them at risk for infection. Findings included: Interview and observation of wound care to Resident #3's feet, on 2/19/25 beginning at 3:11 PM, revealed LVN K gathered supplies for wound care donned gown and removed Resident #3's socks without performing hand hygiene; LVN K completed wound care to Resident #3's feet and washed her hands for 9 seconds. During an interview on 2/19/15 at 3:24 pm, LVN K said she did not perform hand hygiene prior to providing wound care for Resident #3 and was nervous with the state…

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 licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as described in the plan of care for 2 of 3 staff (LVN B and LVN F) reviewed for nursing competencies, in that: The facility failed to ensure LVN B and LVN F followed physician's fentanyl order which resulted in Resident #1 becoming unresponsive and suffering respiratory failure. This failure could place residents at risk for not having medications accurately dispensed, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: Record review of LVN B's Nursing Competency Skills Checklist dated 7/22/24 and signed off by the DON revealed LVN B was marked as competent to perform Transdermal Patches to include fentanyl. Record review of LVN H's Nursing Competency Skills Checklist dated 7/22/23 and signed off by the DON revealed LVN B was marked as competent 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 implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #1 requiring weekly skin assessments. This failure could place residents of risk for not receiving appropriate care and treatment, worsening of skin issues, a delay in treatment, a decline in health, and hospitalization. Findings included: Record review of the face sheet, dated 05/02/2024, indicated Resident #1 was a [AGE] year old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection), and hemiplegia and hemiparesis (paralysis and muscle weakness on one side of the body)…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. Sanitizing buckets were not stored away from food products on 03/24/24. 2. Personal beverages were in a part of the kitchen work area on 03/24/24. 3. The juice machine was not clean on 03/24/24. 4. A couple of milk jugs were opened and not dated on 03/24/24. 5. There was a prepared salad in the refrigerator that was not discarded on the discard date of 03/20/2024. 6. There was a package of cheese stored in the freezer that was open and exposed to the inner freezer environment on 03/24/24. 7. There was not a discard date for cooked eggs that was stored in the freezer with only one date: 3-23 on the package. 8. The handwashing sink did not provide hot running water on 03/24/24. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation during the initial kitchen tour 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 interviews and record reviews the facility failed to ensure 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, for 4 of 24 residents (Residents #15, #50, #52, and #47) reviewed for allegations of abuse, neglect, exploitation, and mistreatment, in that: 1. The Administrator and the DON did not report to the state agency and or investigate Resident #52's incident on 11/22/2023, when she was hospitalized and diagnosed with overdose related to self-medication with Diphenhydramine (an antihistamines; used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; for 1 of 24 residents (Resident #12) reviewed for assistance with showers. The facility failed to provide Resident #12 a shower for 7 days . This failure could place residents at risk for demoralized self-esteem and risk for infections. The findings included: A record review of resident #12's admission record dated 03/25/2024, revealed an admission date of 02/05/2022 with diagnoses which included paraplegia (paralysis of all or part of your trunk, legs), acquired absence of left leg below the knee, and major depression. A record review of resident#12's annual MDS assessment dated [DATE] revealed resident #12 was a [AGE] year-old male admitted for long term care, assessed with a BIMS score of 13 which indicated intact cognition. Further review revealed resident #12 was assessed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide resident preferences for individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 8 residents (Resident #48 and Resident #62) reviewed for activity preference, in that: The facility failed to ensure Resident #48, and Resident #62 received activities to meet their interests. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. The findings included: 1.Record review of Resident #48's face sheet, dated 3/29/2024, reflected Resident #48 was a [AGE] year-old female resident who was initially admitted to the facility on [DATE] with diagnosis of paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), major depressive disorder (a mental health disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility's interdisciplinary team failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 3 of 32 residents (Resident #18) reviewed for revised care plans in that: 1. The facility failed to ensure Resident #18's use of dentures was care planned. 2. The facility failed to ensure Resident #8's care plan was updated after an attempted elopement. These failures could place residents at risk for not receiving appropriate interventions to meet their current and changing needs. The findings included: 1. Record review of Resident #18's face sheet, dated 03/29/2024, reflected a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), parkinsonism (disorder of the central nervous system that affects movement, often…

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 assist residents in obtaining routine dental services and assist the resident with making appointment for 2 of 8 (Residents #18 and #81) residents reviewed for dental services in that: 1. The facility failed to assist Resident #18 in obtaining appropriate dental services after Resident #18's upper dentures became loose and were recommended to be replaced by the dentist. 2. The facility failed to assist Resident #81 in obtaining appropriate dental services after Resident #81 and Resident #81's family requested it due to lack of natural teeth per her annual MDS assessment dated [DATE]. This deficient practice could affect residents who had dentures and place them at-risk by contributing to mouth pain, difficulty eating and weight loss. The findings were: 1. Record review of Resident #18's face sheet, dated 03/29/2024, reflected a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnosis that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide and document sufficient preparation to ensure safe and orderly discharge from the facility for 2 of 3 residents (Resident #2 and #3) reviewed for discharge. 1. The facility failed to ensure Resident #2's home health services and DME were arranged and in place prior to discharge. 2. The facility failed to ensure Resident #3's home health and wound care services were confirmed and in place prior to discharge. These failures could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for their needs not being met. The findings included: 1. Record review of Resident #2's face sheet dated 2/20/2024 revealed an admission date of 11/17/2023 and a discharge date of 1/05/2024 with diagnoses which included: nondisplaced mid-cervical fracture of right femur, subsequent encounter for closed fracture with routine healing (fracture or bone cracks in one place that does not move 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.

Based on interview and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 3 staff (Staff C) reviewed for staff qualifications. The facility failed to ensure Staff C was appropriately licensed to practice social work in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained and supervised. The findings included: Record Review of Staff C's personnel file revealed a document titled Application for Licensed Social Worker dated 12/26/2023. Staff C indicated she graduated with a master's in social work on 12/01/2022. The application revealed she had no long-term care experience and there was no information about a social worker license. Staff C's personnel file revealed there was no licensure information. During an interview on 2/16/2024 at 1:50 p.m., Staff C, identified herself as the facility Social Worker. She stated she worked under the Administrator but was not licensed as a social worker. Staff C stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #1) reviewed for advanced directives, in that: The facility failed to ensure Resident #1's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and signed by two witnesses to the resident's signature which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed an admission date of [DATE] with diagnoses which included: chronic obstructive pulmonary disease with acute lower respiratory infection (chronic inflammatory lung disease that causes obstructed airflow to the lungs with a current respiratory infection), atherosclerotic heart disease of native coronary artery without angina pectoris (narrowing or blockage of the arteries to the heart without associated pain) 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 interview and record review, the facility failed to develop and implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 3 residents (Resident #2 and #3) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #2's care plan included discharge planning and goals. 2. The facility failed to ensure Resident #3's care plan included discharge planning and goals. These failures could affect residents and place them at risk of their discharge wishes not being honored and not receiving appropriate treatment and services on discharge: The findings included: 1. Record review of Resident #2's face sheet dated 2/20/2024 revealed an admission date of 11/17/2023 and a discharge date of 1/05/2024 with diagnoses which included: nondisplaced mid-cervical fracture of right femur, subsequent encounter for closed fracture with routine healing (fracture or bone cracks in one…

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 the medication error rate was not five percent or greater. The facility had a medication error rate of 43% based on 28 errors out of 64 opportunities, which involved 4 of 6 residents (Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for medication errors. - LVN A failed to administer medications as ordered to Resident #3 by administering Aspirin (a blood thinner), Calcium supplement, Cyclosporine (eye drops), Apixaban (a blood thinner), Fenofibrate (a treatment for high cholesterol), Gabapentin (a treatment for nerve pain), multivitamin supplement, Omega-3 supplement, Polyethylene Glycol (a treatment for constipation), Risperidone (a treatment for mood disorder), and Tamsulosin HCl (a treatment for an enlarged prostate) over 1 ½ hours after the scheduled time. - LVN A failed to administer medications as ordered to Resident #4 by administering Hydrocodone-Acetaminophen (a pain reducing medication), Ibuprofen (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs 2 of 12 resident rooms (Resident #1 and Resident #2) reviewed for call lights. The facility failed to ensure Resident #1 and Resident #2's call lights were within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed. Findings included: Record review of Resident #1's face sheet, dated 10/02/2023, revealed the resident was a seventy-seven year-old male admitted to the facility on [DATE] with diagnoses which included: thoracic aortic aneurysm (a bulge in the main artery that carries blood from the heart to the rest of the body), Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors), muscle wasting and atrophy (shrinking of muscle or nerve tissue), and cognitive communication deficit (difficulty communicating due to injury to the brain). Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 of 29 residents (Resident #1) records reviewed for treatment documentation. LVN B documented on 06/22/2023 Resident #1 returned from an offsite appointment at 07:00 p.m. and documented Resident #1 received his 04:00 p.m. medications Furosemide, Buspirone HCl, Lactulose Encephalopathy, Carbidopa-Levodopa without notating the medications were administered late. These failures could place residents at risk of the medical record by not being an accurate representation of their medical condition or medical needs. Findings included: Record review of Resident #1's face sheet, dated 10/02/2023, revealed the resident was a seventy-seven year-old male admitted to the facility on [DATE] with diagnoses which included: thoracic aortic aneurysm (a bulge in the main artery that carries blood from the heart 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 allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 out of 5 resident rooms reviewed for environment. The facility failed to have a working light on the outside of the room that would light up when the resident pushed the call bell for resident room [ROOM NUMBER]. This failure could place residents at risk of not being able to notify staff when care is needed. The findings included: In an observation on 08/16/2023 beginning at 10:43 a.m., three call lights, labeled 83, 94, and 104, were visibly lit on the call light panel and it was beeping behind the nurses' station. LVN A was observed sitting in the nurses' station next to the call light panel. CMA B observed standing next to the nurses' station prepping her medication cart. Call lights observed lit above resident room [ROOM NUMBER] and resident room [ROOM NUMBER] doors. LVN…

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 treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #2) reviewed for quality of care in that: Resident #2 did not receive her schedule wound care for her moisture-associated skin breakdown on her gluteal cleft on 7/26/23 and 7/27/23. This deficient practice could affect residents who receive wound care from the facility staff and place them at risk for worsening skin conditions. The findings were: Record review of Resident #2's face sheet, dated 7/28/23, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of other cerebral palsy [a disorder that affects a person's ability to move and maintain balance and posture], other psychotic disorder not due to a substance or known physiological [physical] condition, major depressive disorder, single episode, unspecified, anxiety disorder, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 of 9 residents (Resident #1) reviewed for pressure ulcers in that: Resident #1 did not receive her scheduled wound care for her right buttock and right shoulder on 7/26/23 and 7/27/23. This deficient practice could affect all residents who receive wound care from the facility staff and place them at risk for worsening of existing pressure ulcers and skin sores or development of new pressure ulcers or skin sores. The findings were: Record review of Resident #1's face sheet, dated, 7/28/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, osteomyelitis [bone infection], 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 2 of 9 residents (Resident #3 and Resident #6) reviewed for drug administration in that: Resident #3 and Resident #6 received their scheduled medications late. This deficient practice could affect all residents and place them at risk for not receiving a therapeutic effect. The findings were: Record review of Resident #3's face sheet, dated 7/28/23, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of other idiopathic peripheral autonomic neuropathy [a disorder of the nervous system that affects the nerves outside of the brain and spinal cord], unspecified protein-calorie malnutrition, essential (primary) hypertension, muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 9 residents (Resident #1 and Resident #7) reviewed for infection control in that: CNA D did not perform hand hygiene appropriately when assisting Resident #1 and Resident #7 with their meals at the same time. The Admissions Director also did not perform hand hygiene appropriately when assisting Resident #1 and Resident #7 with their meals at the same time. This deficient practice could affect all residents who require assistance with meals and place them at risk for infection. The findings were: Record review of Resident #1's face sheet, dated, 7/28/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for food storage, preparation, distribution, and food served in accordance with professional standards for food service safety. 1. The facility failed to ensure expired sandwiches were not stored with ready to serve sandwiches in the facility's refrigerator. 2. The facility failed to ensure dishes were properly washed and sanitized. These failures could place residents at risk for harm by exposure to food borne illnesses, such as Salmonella [a common bacterial disease that affects the intestinal tract]. The findings include: 1. During an observation of the facility's kitchen on 02/09/2023 at 05:23 PM revealed a refrigerator in which ready to serve sandwiches were stored. Further observation revealed 2 ham sandwiches which were stored among other ready to serve sandwiches. The 2 ham sandwiches were sealed in a clear plastic sandwich size Ziplock bag. The bag 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 observations, interviews, and record reviews the facility failed to have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two, for 1 of 1 facility's reviewed for outside ventilation by means of windows, or mechanical ventilation, or a combination of the two, in that: The facility maintained a CMS waiver for recirculating air back into the facility's hallway versus outside ventilation when the facility began painting the interior of the facility, including residents' rooms, without adequate outside ventilation. This failure could place residents at risk for breathing difficulties and breathing emergencies. The findings include: A record review of Resident #81's admission record, dated 02/09/2023, revealed an admission date of 03/02/2023 with diagnoses which included Parkinson's disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]. A 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 observations, interviews, and record reviews the facility failed to ensure residents had the right to and the facility made prompt efforts to resolve grievances the Resident(s) may have and failed to ensure all written grievance decisions included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued, for 2 of 5 Residents (Resident #14 and Resident #88) reviewed for grievances. The facility failed to ensure Residents #18 and #88 grievances were investigated and the Residents were given a report. This failure could have placed residents at risk for harm by not investigating the grievances. The findings include: 1. A 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 ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency in accordance with State law through established procedures, for 2 of 5 residents (residents #14 and Resident #88) reviewed for reporting allegations of abuse and neglect. The facility failed to acknowledge, investigate, and report the allegations of abuse and neglect to the state survey agency on behalf of Resident #14 and Resident #88. This failure could place…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 32 residents (Residents #54) reviewed for care plans. 1. The facility failed to implement Resident #54's care plan to wear an apron while smoking. 2. The faclity failed to revise Resident #54's care plan to reflect the correct suprapubic catheter size. These deficient practices could place residents at risk of missed inadequate care. The findings were: A. Record review of Resident #54's admission Record revealed an admission date of 07/18/18 with a principal diagnosis of Paraplegia (the inability to voluntarily move the lower parts of the body). Record review of Resident #54's quarterly MDS assessment dated [DATE], revealed a BIMS (BIMS test is used to get a quick snapshot of how well you…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to revise the care plan after each assessment for 1 of 32 (Resident #82) reviewed for care plans. 1. The facility failed to revise Resident #82's care plan to reflect the proper diet. This deficient practice could place the residents at risk of not receiving the care and services required. The findings include: A. Record review of Resident #82's admission record revealed an admission date of 05/28/22 with a principal diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #82's MDS assessment dated [DATE] revealed a BIMS Summary Score of 99 (resident was unable to complete the interview). Further review revealed Nutritional Approaches, C. Mechanical altered diet - require change in texture of foods or liquids, e.g., pureed food (a way to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding), thickened liquids (mildly…

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.