Clyde W Cosper Texas State Veterans Home

Based on observation, interview, and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established guidelines and ensure menus were followed for 1 of 2 meals (the lunch meal) reviewed for nutritional adequacy. The facility failed to ensure [NAME] B used a #16 scoop to serve the pureed roll on 04/27/2026. The facility failed to ensure the Assistant Dietary Manager served one cup of the regular chicken cacciatore pasta on 04/27/2026. These failures could place residents at risk of weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: During an observation and interview of the lunch meal in the kitchen on 04/27/2026 starting at 11:22 AM, [NAME] B said she served the lunch meal for the residents who ate lunch in the halls. [NAME] B used a #20 scoop to serve the pureed bread. A size #16 scoop was required. During an observation and interview of the lunch meal in the main dining room on 04/27/2026 at 11:43 AM, the Assistant Dietary Manager said she was using only 1/2 scoops 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 therapeutic diets were prescribed by the attending physician for 1 residents (Resident #2) reviewed for health shakes. The facility failed to ensure Resident #2 received his health shake, as ordered by the physician. This failure could place residents at risk of not maintaining adequate nutritional status including unintentional weight loss. Findings include:Record review of Resident #2 face sheet revealed a male who was admitted to the facility 10/22/2024. Resident #2 had diagnoses which included Parkinson's (difficult movement due to decreased brain function; tremors) and dysphagia of the opharyngeal phase (difficult swallowing food from mouth to throat). Record review of Resident #2 comprehensive MDS, dated [DATE], revealed Resident p#2 had a BIMS of 10, which indicated the resident had moderate cognitive impairment. Resident #2 was dependent on assistance with all eating. Resident #2 had weight loss of 5% or more in one month 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 provide specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity, as required in the resident's comprehensive plan of care for 1 of 7 residents (Resident #67) reviewed for specialized rehabilitative services. The facility did not ensure Resident #67 received physical therapy after a therapy screening on 03/11/26. This deficient practice could place residents at risk of a decline or decrease in their physical capabilities. Findings include: Record review of Resident #67's face sheet, dated 04/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #67 had a diagnosis which included repeated falls. Record review of Resident #67's significant change of status MDS assessment, dated 02/27/26, reflected Resident #67…

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 2 of 7 residents (Resident #73 and Resident #86) reviewed for infection control.1.The facility failed to ensure LVN E wore PPE (gown and mask) while performing a blood sugar check on Resident #73 on 04/28/26, who was on droplet precautions (Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions).2.The facility failed to ensure CNA CC and Nurse DD performed proper glove changes while providing incontinent care to Resident #86 on 4/27/2026.These failures could place residents at risk for cross-contamination and the spread of infection.Finding include:1. Record review of Resident #73's face sheet, dated 04/29/26,…

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 the assessment accurately reflected the resident's status for 1 of 6 residents (Resident #1) reviewed for assessments: The facility failed to ensure Resident #1's Quarterly MDS assessment accurately reflected the use of antidepressants. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #1's face sheet, dated 04/07/2026, revealed an admission date of 11/26/2024 with diagnoses that included Alzheimer's disease (a progressive disorder that is the common cause of dementia (cognitive loss), anxiety (a group of mental illnesses that cause constant fear and worry), delusional disorder (a chronic condition characterized by the presence of one or more false beliefs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), hyperlipidemia (elevated levels of any lipid (fats) in the blood), and osteoarthritis (a joint disease caused by the breakdown 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 review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's wheelchair was properly secured in the facility transport van on 12/05/2025. Resident #1 sustained a contusion to his head when the wheelchair tipped over as the van turned a corner during transport. This failure could place residents transported via facility van at risk for accidents resulting in serious injury. The findings were:Record review of Resident #1's face sheet dated 03/12/2026 revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses that included a cerebral infarction with hemiplegia (a stroke caused by reduced blood flow leading to brain tissue death that limits movement on one side of the body), Osteoarthritis (a joint disease where protective cartilage breaks down, causing bones to rub…

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 liquids consistent with the residents' needs for 2 of 3 (Resident #1 and Resident #2) residents reviewed for liquid inconsistency. 1. The facility failed to ensure LVN A checked the lunch tray appropriately for Resident #1, who required nectar-thick liquids on 11/10/25. 2.The facility failed to ensure Resident #1, and Resident #2 did not have thin liquids at their bedside on 11/11/25. These failures could affect residents by placing them at risk for aspiration and not receiving appropriate interventions to meet their current needs.Findings included: 1. Record review of Resident #1' face sheet dated 11/12/25, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included Parkinson's (a progressive brain disorder that affects movement, primarily caused by the death of brain cells that produce dopamine), and dysphagia (difficulty swallowing, where food or liquids cannot move easily from the mouth…

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 residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 4 of 32 residents (Resident #402, Resident #401, Resident #22, and Resident #45) reviewed for trauma-informed care. 1.The facility did not ensure Resident #402 had a trauma screening completed upon admission that identified possible triggers when Resident #402 had a history of trauma and PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). 2. The facility did not ensure Resident #401 had a trauma screening completed upon admission. 3. The facility did not ensure Residents #22 and #45 care plan identified possible triggers when Residents #22 and #45 had a history of trauma. These failures could…

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 that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 32 residents (Resident #103), 1 of 13 medication carts (600 hall Nurse Medication Cart), and 1 of 2 medication storage rooms (Secure Unit Medication Room) reviewed for drugs and biologicals. The facility failed to ensure LVN M secured the 600 hall Nurse Medication Cart, when it was not in use on 02/03/2025. The facility failed to ensure a lock box in the Secure Unit Medication Room refrigerator with 4 bottles of Ativan (controlled medication for anxiety) was permanently affixed. The facility failed to ensure a lock box inside the cabinets in the Secure Unit Medication Room with 2 bottles of morphine (controlled pain medication) and 2 bottles of hydromorphone (controlled pain medication) was permanently affixed. The facility did not ensure Resident #103's Cold & Flu cough syrup and Aleve liquid gels (pain…

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 laboratory services were obtained to meet the needs of 3 of 7 residents (Resident #49, Resident #22, and Resident #103) reviewed for laboratory services. 1. The facility failed to ensure Resident #49's T4 Free and a PSA lab test were drawn yearly. T4 Free (a test that measures the amount of free thyroxine (T4) in the blood. T4 is a hormone produced by the thyroid gland that plays a vital role in metabolism). Prostate-Specific Antigen also known as PSA test (blood test that measures the amount of (PSA) in your blood. It can help to diagnose prostate cancer. 2. The facility failed to ensure Resident #49's Vitamin D test was drawn every 6 months. (Vitamin D measures the levels of vitamin D in your blood. Vitamin D helps your body absorb calcium to build healthy bones and teeth). 3. The facility did not obtain a physician's ordered Free T4 (hormone test that measures the amount of active thyroid hormone (T4) in the bloodstream for Resident's #22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 3 of 32 residents (Resident #49, Resident #95, and Resident # 39) reviewed for infection control. 1. The facility failed to ensure MA BB wore PPE while entering Resident #49's room while on contact isolation precautions on 02/04/25. 2. The facility failed to ensure Housekeeper NNN wore PPE while cleaning Resident #49's room while he was on contact isolation precautions on 02/04/25. 3. The facility did not ensure LVN E performed hand hygiene while providing wound care to Resident #95. 4. The facility did not ensure LVN E disinfected Resident #95's dresser prior to exiting the room. 5. The facility failed to ensure LVN XX performed hand hygiene between glove changes while providing catheter care 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 treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 32 residents (Resident #2) reviewed for resident rights. The facility failed to ensure CNA FFF treated Resident #2 with respect and dignity when Resident #2 asked CNA FFF to provide incontinent care before he ate his lunch and CNA FFF failed to comply with Resident #2's request during lunch on 02/03/25 and she told him I just changed you 5 minutes ago. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth. Findings included: Record review of Resident #2's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of bipolar disorder (disease characterized by periods of depression and elevated moods), anxiety disorder (feelings of dread over anticipated events), history of traumatic brain…

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 right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 1 of 5 residents (Resident #59) reviewed for restraint use. The facility failed to ensure Resident #59 was free of physical restraints when CNA ZZ held his wrist against the bed while providing care on 02/03/2025. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury. Findings included: Record review of a face sheet dated 02/05/2025 indicated Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included vascular dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition caused by lack of blood that carries oxygen and nutrients to a part of the brain and can cause problems with reasoning, planning, judgment, and memory) 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 ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 2 of 14 residents (Residents #55 and #61) reviewed for PASRR. The facility did not ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Residents #55 and #61 who had a diagnosis of mental illness upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1. Record review of Resident #61's face sheet, dated 02/07/25, reflected Resident #61 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included PTSD (a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 resident (#402) of 12 residents reviewed for baseline care plans. The facility failed to address Resident #402's PTSD diagnosis and triggers in his baseline care plan. This deficient practice could affect residents who are admitted to the facility with specialized needs and result in missed care. The findings were: Record review of Resident #402's face sheet dated 02/07/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis's alcohol abuse, chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation), metabolic encephalopathy (condition where the brain does not function related to the an imbalance in the body's metabolism and causes…

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 2. Record review of a face sheet dated 02/05/2025 indicated Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition caused by lack of blood that carries oxygen and nutrients to a part of the brain and can cause problems with reasoning, planning, judgment, and memory). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #59 was able to make himself understood and understood others. The MDS assessment indicated Resident #59 had a BIMs score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #59 required partial to moderate assistance with toileting, showering/bathing self, personal hygiene, and dressing. The MDS assessment indicated Resident #59 did not exhibit rejection of care. Record review of Resident #59's care plan last reviewed 12/19/2024 did not…

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 that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 7 residents reviewed for respiratory care (Resident #105). The facility failed to ensure Resident #105's oxygen mask tubing was changed out and dated on 01/29/25. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: Record review of Resident #105's face sheet indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), chronic obstructive pulmonary disease (chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation), heart failure (condition in which the heart does not pump as well as it…

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 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 32 residents (Resident # 93 and Resident # 114) reviewed for pharmacy services. The facility failed to ensure Resident #93's blood pressure met the parameters for the administration of an anti-hypertensive medication on 01/16/2025 and on 01/27/2025. The facility failed to ensure Resident #114's blood pressure met the parameters for the administration of an anti-hypertensive medication on 01/03/2025 and on 01/16/2025. These failures could place residents at risk of serious harm, not receiving their medications as ordered, illnesses, hospitalizations, exacerbation of their disease processes, coma, and death. Findings included: 1.Record review of the face sheet dated 02/06/2025, indicated Resident # 93 was an [AGE] year-old male admitted to 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 observations, interviews, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident's #30 and #299) reviewed for infection control practices related to droplet precautions and 4 of 11 facility staff members (MA C, LVN A, LVN F, and Speech Therapist D) reviewed for infection control practices related to medication pass and droplet precautions. The facility further failed to ensure facility personnel handled, stored, processed, and transported linens so as to prevent the spread of infection for 1 of 5 staff members (CNA N) reviewed for transportation of linens. 1. The facility failed to ensure LVN A, MA C, Speech Therapist D wore the appropriate PPE when entering Resident #30's and Resident #299's room. 2. The facility failed to ensure LVN F removed her PPE prior to exiting Resident #30's 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, and interview the facility failed to coordinate assessments with pre-admission screening and resident review (PASARR ) program under Medicaid to the maximum extent practicable to avoid duplicative testing effort which included referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment ensure a PASRR screening was completed for residents with mental disorders or an intellectual disability for 4 of 7 residents (Residents #129, #26, #57, and #121) reviewed for PASRR Level I screenings. The facility failed to ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Residents #129, #26, #57,…

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 environment remained free of accidents hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Resident #33 and Resident #92) and 2 of 7 halls (Halls 700 and 800) reviewed for accidents and supervision. 1. The facility failed to ensure the bathroom for Resident #33 and Resident #92 was free of leaking water. 2. The facility failed to ensure the Residents on Hall 700 and Hall 800 were adequately supervised. These failures could put residents at risk of serious bodily harm, physical impairment, or death. Findings Include: 1.Record review of Resident #33's face sheet, dated 01/25/24, indicated Resident #33 was an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted [DATE]. Resident #33 had diagnoses which included arthritis (causes joint pain, stiffness, and inflammation), leg cramps (painful, involuntary muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 1 of 9 residents with a nebulizer machine (Resident #57) and 4 of 11 residents who received oxygen (Resident's #130, #47, #57, and #81) that were reviewed for respiratory care. 1. The facility failed to ensure Resident #47 oxygen was placed on 2 LPM as ordered by the physician. 2. The facility failed to administer oxygen at 2L via nasal cannula as prescribed by the physician for Resident #57. 2a. The facility failed to properly store Resident #57's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. 3. The facility failed to ensure Resident #130's nasal cannula tubing was changed weekly. 3a. The facility failed to ensure Resident #130's nasal cannula tubing was changed weekly. 4. The facility failed to ensure Resident #81's oxygen…

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 all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 3 residents (Resident #12) reviewed for medications at their bedside and 1 of 6 (500 Hall) medication carts reviewed for storage of medications. 1. The facility did not ensure Resident #48's Nystatin Powder was not unsecured in Resident #12's room. 2. The facility did not ensure LVN A kept the medication cart on 500 Hall locked or within her line of site, while administering medications. This failure could place residents at risk for misuse of medication and overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. The findings included: 1. Record review of Resident #48's face sheet, dated 01/25/2025, indicated Resident #48 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure). Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 3 of 4 residents (Resident #62, Resident #6, and Resident #127) reviewed for smoking. The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #62, Resident #6, and Resident #127. This failure could place residents at risk of unsafe smoking and injury. Findings included: Record review of Resident #62's face sheet, dated 01/25/24 indicated Resident #62 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Involuntary movements (a group of uncontrolled movements that may manifest as a tremor), Blindness to left eye and diabetes (a condition that happens when your blood sugar (glucose) is too high). Record review of Resident #62's quarterly MDS assessment, dated 12/21/23, indicated Resident #62 was understood and understood by others . Resident #62's BIMs score was 15,…

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 conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional for 1 of 30 residents (Resident #57) reviewed for comprehensive assessments and timing. The facility did not ensure Resident #57's admission MDS assessment was completed within 14 days of admission. This failure could place residents at risk of not having their needs identified and met. Findings included: Record review of Resident #57's face sheet, dated 01/25/2024, indicated Resident #57 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included Stage 4 chronic kidney disease (moderately or severely loss of kidney function). Record review of Resident #57's comprehensive MDS assessment, with an ARD of 01/17/2024, indicated in Section A0310 it was an admission assessment (required by day 14). The MDS assessment for Resident #57 indicated in Section A1600 an entry date of 01/08/2024.…

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 interviews and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 7 residents reviewed for care plans related to PTSD. (Resident #68) The facility failed to ensure Resident #68's care plan reflected his diagnosis of PTSD, that included triggers for potential re-traumatization. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and potential re-traumatization. The findings included: Record review of the face sheet, dated 01/25/24, revealed Resident #68 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Record review of the quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 2 of 30 (Residents #57 and #299) residents reviewed for ADL care. 1. The facility did not ensure Resident #57 was provided his scheduled bath/showers. 2. The facility failed to ensure Resident #299 received his shower as scheduled on 01/22/2024. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: 1. Record review of Resident #57's face sheet, dated 01/25/2024, indicated Resident #57 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnoses which included Stage 4 chronic kidney disease (moderately or severely loss of kidney function). Record review of Resident #57's admission MDS, dated [DATE], indicated Resident #57 understood others and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed 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 1 of 6 residents (Resident #85) reviewed for medication administration. The facility did not ensure Resident #85's furosemide (diuretic), metoprolol tartrate (blood pressure medication), valproic acid (anticonvulsant), and lacosamide (anticonvulsant) labels from the pharmacy matched the orders placed in the electronic charting system. This failure could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs. The findings included: Record review of the face sheet, dated 01/25/2024, revealed Resident #85 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (long-term…

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 were free of significant medication errors for 1 of 2 residents reviewed for insulin administration. (Resident #300) The facility did not ensure LVN A administered Resident #300's Novolog (insulin aspart) FlexPen (insulin medication) according to the manufacturer's instructions. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of the face sheet, dated 01/25/2024, revealed Resident #300 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (a condition that results from insufficient production of insulin, causing high blood sugar). Record review of Resident #300's MDS assessment revealed it was not due to have been completed yet. Record review of the comprehensive care plan, initiated on 01/16/2024, revealed Resident #300 was at risk 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 assist residents in obtaining routine dental services to meet the needs of 1 of 2 (Resident #124) residents reviewed for dental services. The facility failed to ensure Resident #124 received dental services when he had jagged, black teeth and missing teeth. This failure could place residents at risk of not receiving needed dental care, difficulty eating, toothaches, tooth infections, and a decreased quality of life. Findings included: Record review of a face sheet dated 01/25/2024 indicated Resident #124 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included chronic diastolic congestive heart failure (the heart's main pumping chamber, left ventricle, becomes stiff an unable to fill properly) and atrial fibrillation (irregular often rapid heartbeat). Record review of the Comprehensive MDS assessment indicated Resident #124 was able to make himself understood and understood others. The MDS assessment…

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 develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 1 of 21 employees (ADON) reviewed for required annual trainings. The facility failed to ensure the ADON received required restraint training annually in January 2023. The facility failed to ensure the ADON received required HIV training annually in January 2023. This failure could place residents at risk for inappropriate restraints and exposure to HIV. The Finding included: Record review of the Facility Personnel file undated indicated, ADON was hired 01/23/18 and the HIV training was last completed on 3/27/23. The facility did not complete ADON's HIV training in January of 2023. The HIV training for the ADON was 2 months late. Record review of the Facility Personnel file undated indicated, ADON was hired 01/23/18 and the restraints training was last completed on 3/27/23. The facility did not complete ADON's restraints training in January of 2023. The restraints training for the ADON was 2…

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 records review the facility failed to ensure residents were free of any significant medication errors for 2 of 7(Resident #3 and Resident #4) residents reviewed for medication errors. The facility failed to ensure Resident #3 received only medication he was prescribed. The facility failed to ensure Resident #4 received long-acting insulin instead of short-acting insulin. The noncompliance was identified as PNC. The noncompliance began on 1/14/23 and ended on 5/30/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for not receiving the intended therapeutic benefit of the medications or experiencing adverse reactions relating to receiving a medication that was not ordered for them. Finding Include: 1. Record review of the face sheet dated 11/22/23 indicated Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (a type of progressive…

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.