North Star Ranch Rehabilitation and Healthcare Cen

Based on observation and interview, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 2 of 2 halls (east hall and west hall) reviewed for quality of care. The facility failed to ensure the shelves located on the east hall and west hall were free from rough edges. These failures could place residents at risk of accidents that could result in injury or harm.Findings included: During an observation on 06/30/2026 at 11:15 AM, the east hall had shelving attached directly to the hall wall that had jagged, rough edges. During an observation on 06/30/2026 at 11:22 AM, the west hall had shelving attached directly to the hall wall that had jagged, rough edges. During an interview on 06/30/2026 at 11:28 AM, the Maintenance Supervisor said he was aware that the shelves on the east and west halls had jagged, rough edges, but it was because he did not have time to sand the edges of the shelves. The Maintenance Supervisor said he placed the shelves on the east and west halls, and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4's physician's order for his enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) indicated the strength of the enteral feed and the specific administration method.This failure could affect residents receiving enteral nutrition and hydration and place them at risk of dehydration, weakness and malnutrition.Findings included:Record review of Resident #4's face sheet, dated 07/02/26, reflected Resident #4 was a [AGE] year old male, admitted to the facility on [DATE] with diagnose which included gastrostomy status (the presence of a surgically placed feeding tube through the abdomen), unspecified protein-calorie malnutrition and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 18 residents (Resident #28) reviewed for storage and labeling of medications and 1 of 2 (East Hall nurse) medication carts reviewed for storage of medications. 1. The facility did not ensure Resident #28's Triamcinolone Acetonide cream (corticosteroid used to reduce inflammation, redness, and itching) was properly secured.2. The facility failed to ensure LVN M locked the east hall nurse's cart when left unattended in the hallway. These failures could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: 1. Record review of Resident #28's face sheet, dated 07/02/26, reflected Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 2 of 2 residents (Residents #2 and #28) reviewed for food preferences and the accommodation of resident's meal choices. 1. The facility failed to ensure Resident #2's preference for large portions was honored on 06/29/26 and 06/30/26. 2. The facility did not ensure Resident #28's preference for over easy eggs was honored on 06/29/26 and 06/30/26. These failures could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings include: 1. Record review of Resident #2's face sheet, dated 07/02/26, reflected Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included morbid (a chronic disease characterized by a body mass index of 40 or higher accompanied by severe weight-related health complications) (severe) obesity due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to maintain medical records in accordance with the accepted professional standards and practices that are complete and accurately documented for 2 of 2 (Resident #9 and Resident #24) residents reviewed for documentation. Resident #9 and Resident #24's electronic medical record did not contain complete and accurate documentation that reflected that the resident or the responsible party were informed of and attended or declined to attend the quarterly care conference meeting. This failure could result in the residents' records not accurately documenting participation in the plan of care.The findings included: Record review of Resident #9's face sheet dated 07/02/2026 revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included COPD (Chronic Obstructive Pulmonary Disease, a progressive, irreversible lung disease that restricts airflow and makes breathing difficult), seizures (sudden, uncontrolled bursts of electrical activity in that 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 interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #12, and Resident #27) reviewed for hospice services.1.The facility failed to maintain Resident #12's hospice binder containing information related to hospice services provided for the resident such as the most recent medication profile, last two months of IDG also known as Interdisciplinary Group meetings (a regular, collaborative team review of a patient's care meetings), or updated recertification form.2.The facility failed to ensure Resident #27's Hospice binder included an up to date and accurate medication profile.These failures could place residents who receive hospice services at risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the discharge information was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 1 of 6 (Resident #1) residents reviewed for transfer and discharge process. The facility failed to ensure the necessary information, including a discharge summary was included in Resident #1's discharge with applicable information to include contact information of the practitioner responsible for the care of the resident, Advance Directive information, special instructions or precautions for ongoing care, and comprehensive care plan goals, was completed. This failure could result in poor continuity of care and harm or injury to resident during transition of care. Findings included: Record review of Resident #1's face sheet dated 03/06/2026 revealed a [AGE] year-old female admitted [DATE] and discharged [DATE] with diagnoses that included cerebral infarction with right…

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 maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or the resident preferences indicated otherwise for 4 of 4 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for nutrition status. 1.The facility failed to follow dietary recommendations for Resident #1. Resident # 1 lost 8.2 lbs. from 12/03/2025 to 01/12/2026 which was a significant weight loss of 5.0%. 2. The facility failed to follow dietary recommendations for Resident #2. Resident #2 lost 16.9 lbs. from 12/04/2025 to 01/12/2026 which was a significant weight loss of 5.5% in 1 month. 3. The facility failed to follow dietary recommendations for Resident #3. Resident #3 had a re-opened left dorsal foot graft site with a low albumin level. 4. The facility failed to follow dietary…

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 sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed and 3 of 20 residents (Resident #2, Resident #4, and Resident #5) for care and services. 1. The facility failed to ensure Resident #2 medications were administered during the scheduled time. 2. The facility failed to ensure sufficient staff was provided to ensure Resident #4 received her showers on Saturdays. 3. The facility failed to ensure sufficient staff was provided to ensure Resident #5 was able to get out of bed when requested. 4. The facility failed to provide sufficient nursing staff according to the facility assessment on 05/03/2025, 05/04/2025, 05/10/2025, 05/11/2025, 06/20/2025, 06/21/2025, 06/28/2025, 07/01/2025, 07/05/2025, 07/06/2025, 07/12/2025, 08/02/2025, 08/03/2025, 09/01/2025, 09/20/2025, 09/21/2025, 10/5/2025, 10/12/2025,…

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 observations, interviews, and record review the facility failed provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2 medications were administered during the scheduled time. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.Findings included: 1. Record review of Resident #2's face sheet, dated 10/23/25, reflected Resident #2 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Parkinson's (a disorder that affects movement, balance, and coordination) with dyskinesia (involuntary, uncontrolled, and abnormal muscle movements). Record review of the order summary report dated 10/23/25 indicated Resident #2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 9 residents (Resident #4) reviewed for quality of life. The facility failed to provide Resident #4's showers as scheduled on Saturdays. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life. Findings included: Record review of a face sheet dated 10/23/2025 indicated Resident #4 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included unspecified combined systolic and diastolic congestive heart failure (heart is unable to pump enough force to push enough blood into circulation) and schizoaffective disorder bipolar type (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech…

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

Based on interview and record review the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition service for 1 of 4 dietary staff (Dietary Aide G). The facility failed to ensure that dietary staff (Dietary Aide G) serving in the kitchen maintained a current Food Handler Certificate. This failure could place residents at risk of the facility not having staff to provide dietary services requirements. Findings included: During an interview on 10/21/2025 at 2:28 PM, the Dietary Manager said Dietary Aide G's food handler certificate was expired. Record review of Dietary Aide G's employee file indicated her date of hire was 07/17/2025, and her Texas Food Handler Certificate was issued 10/06/2022 and expired 10/05/2024. During an interview on 10/21/2025 at 4:21 PM, the Dietary Manager said the food handler certificate should be obtained within 30 days of hire. The Dietary Manager said she did not pay attention to when Dietary Aide G's food handler certificate expired. The Dietary Manager said she and the human resources department were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to provide rehabilitative services as the physician ordered, for 1 (Resident #5) of 12 residents reviewed for rehabilitative services. The facility failed to ensure that Resident #5 received physical therapy (PT) or occupational therapy (OT) treatments as ordered by the physician from 06/16/25 through 06/20/25 and again from 06/23/25 through 06/24/25. This deficient practice could place residents who require rehabilitative services at risk of a decline or decrease in their physical capabilities.The findings included: Record review of Resident #5's face sheet, dated 10/23/25, indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation (an irregular heartbeat, or arrhythmia), muscle weakness, unsteadiness on her feet, and cognitive communication deficit. Record review of Resident #5's OBRA (Omnibus Budget Reconciliation Act) MDS dated [DATE] indicated a BIMS score of 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 observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 4 of 7 residents reviewed for environment. (Resident #1, Resident #2, Resident #3, and Resident #4). The facility failed to ensure Residents #1, #2, #3 and #4's heating and cooling vents, within the rooms they resided in, were not covered in black mold like substance on 5/24/25. This failure could cause decreased quality of life, and health complications of respiratory issues. Findings included: 1. Record review of the face sheet dated 5/24/25 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system characterized by a loss of nerve cells in the brain that produce dopamine. The disorder leads to the manifestation of motor symptoms like tremors, muscle stiffness, and slow movement), muscle weakness, depression, and type II diabetes. Record review of 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 all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 7 resident (Resident #1) reviewed for medications at their bedside. The facility did not ensure Resident #1's was administered his Protonix pill (a proton pump inhibitor used to treat GERD [gastroesophageal reflux disease a common digestive disease in which stomach acid or bile irritates the food pipe lining]) during his morning medication pass on 5/24/25 and left the unlabeled, unsecured medication on Resident #1's bedside table for several hours. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: Record review of the face sheet dated 5/24/25 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a 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.

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 18 resident (Resident #103) reviewed for medications at their bedside. The facility did not ensure Resident #103's fluticasone propionate (nasal spray), biotene dry mouth Moisturizing Spray, and barbasol shaving cream were secured in locked compartments and not left on his bedside table and windowsill. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: Record review of Resident #103's face sheet, dated 04/23/25, reflected Resident #103 was an [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included metabolic encephalopathy (brain dysfunction caused by chemical imbalance in the blood). Record review of Resident #103's physician order summary report,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 4 of 4 eyewash stations reviewed (kitchen eyewash, laundry eyewash station, east wing medication room eyewash station, and east wing shower room eyewash station) reviewed for physical environment. The facility failed to ensure the Saline eyewash solutions located in the kitchen, the medication room on east wing, the laundry, and the shower room were within the date of expiration. Findings included: During an observation on [DATE] at 10:25 AM the two bottles of saline eyewash solution in the kitchen at the eyewash station were out of date and labeled with an expiration date of 10/2024 for the left-side bottle and 01/2025 for the right-side bottle. During an observation and interview on [DATE] at 8:10 AM the bottle of saline eyewash solution in the east wing medication room was expired with an expiration date of 7/2024 on the bottle.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 4 of 8 residents (Residents #103, #35, #203, and #36) reviewed for oxygen therapy. 1. The facility failed to ensure Resident #103 had physician's order in his chart for oxygen. 2. The facility failed to ensure Resident #35 's oxygen was placed on 2 liters per nasal cannula as ordered by the physician. 3.The facility failed to ensure Resident #203 had an oxygen order and an oxygen sign on her door. 4.The facility failed to ensure Resident #36 had orders for oxygen. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. Findings Included: 1. Record review of Resident #103's face sheet, dated 04/23/25, reflected Resident #103 was an [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included…

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

Based on observation, interview, and record review the facility failed to provide residents with food and drink that was palatable, attractive, and at a safe and appetizing temperature for 4 of 18 residents (Resident #31, Resident #47, Resident #8, and Resident #42) and 1 of 3 meals observed. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #47, Resident #31, Resident #8, and Resident #42. The facility failed to provide food that was palatable for 1 of 3 meals observed on 04/22/25 (lunch) meal. This failure could place residents at risk of decreased food intake, weight loss, altered nutritional status, and a diminished quality of life. Findings include: During an interview on 04/21/25 at 11:55 AM Resident #31 stated when staff bring her food it's cold. Stated it makes her sad and pissed. Staff was aware of her food complaints but unable to recall names of staff who were aware of her food complaints. During an interview on 04/21/25 at 12:07 p.m., Resident #8 said the food was cold, and sometimes it had no taste. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure consent to the prescription of psychoactive medications given by a resident or by a person authorized by law to give consent on behalf of the resident is valid only if consent is given in writing on a form prescribed by HHSC for 1 of 18 (Residents #1) residents reviewed for psychoactive medications. The facility did not ensure written consent was obtained from the legal authorized representative on HHSC Form 3713 to administer Seroquel 25mg to Resident #1. This failure could place residents at risk for receiving antipsychotic medications without informed consent. Findings included: Record review of Resident #1's face sheet, dated 04/23/25, reflected Resident #1 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect your mood) and bipolar (a disorder associated with episodes of mood swings ranging from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 18 residents (Resident #45) reviewed for reasonable accommodations. The facility did not ensure portable oxygen was available to allow Resident #45 to leave his room. This failure could place residents at risk for decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #45's face sheet, dated 04/23/25, reflected Resident #45 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #45's physician order summary report, dated 04/23/24, reflected an active physician's order for oxygen at 2-3 liters per minute via N/C continuously with 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 interview and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 1 of 18 residents (Resident #37) reviewed for advanced directives. 1. The facility did not ensure Resident #37's OOH-DNR included the MPOA printed name and date the document was signed. 2. The facility did not ensure Resident #37's OOH-DNR included the notary's signature. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #37's face sheet, dated 04/23/25, reflected Resident #37 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included Parkinson's (brain disorder that causes unintended or uncontrollable movements). Record review of Resident #37's physician order summary report, dated 04/23/25, reflected an active physician's order for code status: DNR with an order date 12/15/23. Record review of Resident #37's quarterly MDS assessment, dated 04/21/25,…

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 each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #104) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #104 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #104's face sheet, dated 04/23/25, reflected Resident #104 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood). Record review of Resident 104's annual 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 interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 18 (Resident #11) residents reviewed for abuse and neglect. The Abuse Coordinator failed to identify and report an allegation of abuse to HHSC within 2 hours when LVN E informed him on 04/22/25 that CNA D witnessed Resident #16 hit Resident #11 right arm. This failure to report could place the residents at risk for abuse. Findings included: Resident #11 Record review of Resident #11's face sheet, dated 04/24/25, reflected Resident #11 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). Record review of Resident #11'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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property were thoroughly investigated for 1 of 18 residents (Resident #11) reviewed for abuse. The Abuse Coordinator failed to investigate/protect/correct when an allegation of abuse allegedly occurred when LVN E informed him on 04/22/25 that CNA D witnessed Resident #16 hit Resident #11 right arm. This failure could place residents at risk for abuse, neglect, exploitation, mistreatment, and further injuries of unknown source. Findings included: Resident #11 Record review of Resident #11's face sheet, dated 04/24/25, reflected Resident #11 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood…

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 assessments accurately reflected the resident status for 2 of 18 residents (Residents #16 and #30) reviewed for MDS assessment accuracy. 1. Resident #16's quarterly MDS, dated [DATE], identified the resident had a feeding tube. However, Resident #16 did not have a feeding tube. 2. Resident #30's quarterly MDS, dated [DATE], identified the use of restraint for Resident #30. However, Resident #30 had a transfer assist bar (bar used on the side of the bed to help with movement). These failures could place residents at risk of not receiving adequate care and services to meet their needs. Findings included: 1. Record review of Resident #16's face sheet, dated 04/23/25, reflected Resident #16 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included paranoid schizophrenia (a person feels distrustful and suspicious of other people and acts accordingly). Record review of Resident #16's quarterly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 2 of 5 (Resident #203 and Resident #36) residents reviewed. The facility failed to care plan Resident #203 and Resident #36's oxygen. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #203's face sheet, dated 04/24/25, indicated an [AGE] year-old female who was admitted to the facility on 03/27 /25 with diagnoses which included urinary tract infection, also known as a UTI (is an infection in any part of the urinary system), stroke, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and high blood pressure. Record review of Resident #203's admission 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.

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 unnecessary medication for 1 of 9 residents reviewed for unnecessary medication (Resident #40) The facility did not monitor Resident #40 for side effects of the anticoagulation medication, Eliquis (a blood-thinning medication). This failure could place the residents at risk for adverse consequences of the anticoagulant medication. Findings included: Record review of a face sheet dated 04/25/25 indicated Resident #40 was a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with a diagnosis of atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), and atherosclerotic heart disease (a condition where plaque buildup narrows the arteries that supply blood to the heart, leading to a reduced blood flow and oxygen delivery to the heart muscle). Record review of Resident #40's care plan, initiated on 10/17/24, indicated an anticoagulant medication of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 18 residents (Resident #25) reviewed for laboratory services. The facility failed to ensure Resident #25's Comprehensive Metabolic Panel, also known as CMP (a blood test that checks for a wide range of substances in your blood, including proteins, enzymes, electrolytes, and minerals) was drawn every 6 months as ordered. Also, his Phenobarbital (used to control seizures) and Dilantin (an anti-seizure medication) levels were not drawn every 3 months as ordered. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Finding included: Record review of Resident #25's face sheet, dated 04/24/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included seizures, anemia (a condition where the blood doesn't have enough healthy red blood cells…

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 promptly notify and follow-up with the ordering physician regarding laboratory results outside of clinical reference range for 1of 18 residents (Resident #1) reviewed for laboratory services. 1. The facility did not ensure the physician was notified when Resident #1's Dilantin (used to control seizures) and Phenobarbital (used to control seizures) level was low. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Findings included: Record review of Resident #1's face sheet, dated 04/23/25, reflected Resident #1 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnosis which included seizures (sudden, uncontrolled electrical disturbance in the brain). Record review of the order summary report, dated 04/23/25, reflected an active physician order for Phenytoin (Dilantin) 100 mg: 1 tablet by mouth BID related seizures with a start date 04/22/25. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to follow menus for 1 of 12 residents (Resident #4) meal reviewed for menus. The facility did not ensure Resident #4 received ground chicken fried chicken as ordered instead of ground beef patty. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #4's face sheet, dated 04/24/25, reflected Resident #4 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included myocardial infarction (heart attack). Record review of Resident #4's physician order summary report, dated 04/24/25, reflected an active physician's order for a mechanical diet with a start date 04/21/25. Record review of Resident #4's quarterly MDS assessment, dated 03/26/25, reflected Resident #4 usually made himself understood, and usually understood others. Resident #4's BIMS score was 4, which indicated his cognition was severely impaired.…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that: 1) The facility failed to ensure the ice scoop holder did not have sediment in the bottom. 2) Dietary staff failed to dispose of expired boiled eggs in the refrigerator dated 04/03/25. These failures could place residents at risk for food contamination and foodborne illness. The findings include: Record review of the facility daily cleaning list date 04/10/25-04/17/25 indicated 04/17/25 was the last date the ice scoop holder in the facility was cleaned and no other list was provided. During an observation on 04/21/25 at 10:25 AM the facility refrigerator had a bag of boiled eggs dated 04/03/25 with no other date on it. During an observation on 04/21/25 at 11:15 AM the ice scoop holder at the main dining room ice machine had orangish-brown sediment in the bottom of it. During an observation on 04/22/25 at 12:10 PM the ice scoop holder continued…

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 establish policies regarding smoking areas, and smoking safety for 1 of 1 smoking area. The facility failed to ensure cigarettes were not discarded in the trash can designed for the disposing of trash. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings Included: During an observation of the and interview on 04/22/25 at 11:05 a.m., there was a trash can with a cigarette that had been smoked noted inside the trash can located in the designated smoking area. Laundry Aide EE stated whoever takes the residents out to smoke should check the trash can for cigarettes. Laundry Aide EE stated the trash can should not have cigarettes inside, only trash. Laundry Aide EE stated this failure could put residents at risk for a fire. During an interview on 04/24/25 at 3:54 p.m., the Administrator stated cigarettes should be extinguished in the receptable, not a trash can. The Administrator stated whoever takes the residents out to smoke should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but , but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 6 (Resident #1) residents reviewed for abuse and neglect. The facility staff did not report to the state agency Resident #1's fractured orbital floor (a break to the thin, bony plate that forms the bottom of the eye socket) and cervical spine fractures, following a fall out of bed during care, that were discovered during a hospital admission starting 1/30/25. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: 1. Record review of the face sheet dated 2/26/25 indicated…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to label and date all food items in the refrigerator and freezer #1. 2) Dietary staff failed to dispose of expired food items. 3) Dietary Staff failed to store (1) dented cans in a separate area. 4) Dietary Staff failed to effectively reseal, label and date frozen food items. 5) The dietary staff failed to maintain safe temperatures at or above 135 degrees F for hot foods. 6) The facility failed to store raw foods (ground turkey) in a manner to reduce the risk of contamination of cooked or ready-to-eat foods. 7) The dietary staff failed to clean the microwave after use. 8) The dietary staff failed to properly dispose of used gloves and used hair net. 9) The dietary staff failed to clean the toaster after use. 10) The dietary staff failed to clean the utensil drawer. 11) The dietary staff failed to clean the clean the floors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in 2 of 2 halls (hall 100 and hall 200) reviewed for a clean and homelike environment. 1. The facility failed to ensure hall 200 was free of a urine odor. 2. The facility failed to deep clean several room floors on Hall 100. 3. The facility failed to ensure the wallpaper for Resident #45 was not peeling/torn. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. The findings included: 1. During observation on 3/4/24 at 1:30 p.m., hall 200 had a strong urine odor. During observation on 3/5/24 at 8:31 a.m., hall 200 had a strong urine odor. During observation on 3/6/24 at 8:04 a.m., hall 200 had a strong urine odor. During an interview on 3/6/24 at 11:46 a.m., Housekeeping aide A stated she had been employed at the facility since August of 2023. Housekeeping aide A stated the halls…

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 develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 3 of 4 (Resident #9, Resident #16, and Resident #43) residents reviewed. 1. The facility failed to care plan Resident #9's fall and/or intervention, diagnoses, and medication use of Xanax (a medication used for generalized anxiety disorder). 2. The facility failed to care plan Resident #16's intervention, diagnoses, and medication use of diagnosis Eliquis {Apixaban} (an anticoagulant medication used to help prevent blood clots). 3. The facility failed to have a care plan related to Resident #43's [NAME] button and extension used for enteral feedings. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1.Record review of…

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

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 4 (Resident #16) who were reviewed for respiratory care. The facility failed to ensure Resident #16 had orders for her Bipap machine (a type of ventilator-a device that helps with breathing). This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #16's face sheet, dated 03/06/24, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety (persistent and excessive worry that interferes with daily activities), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), chronic obstructive pulmonary disease or COPD, ( a group of diseases that cause airflow blockage and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for 1 of 1 resident reviewed (Resident #16) for respiratory care. The facility failed to ensure nurses were trained on the use of a Bipap machine (a machine that helps you breathe) for Resident #16. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize respiratory issues. The findings included: Record review of Resident #16's face sheet, dated 03/06/24, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety (persistent and excessive worry that interferes with daily activities), sleep apnea (a potentially serious sleep disorder in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 16 residents (Resident #36) reviewed for MDS transmittal. The facility did not ensure Resident # 36's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted and accepted as required as of 03/06/2024. This deficient practice could place residents at risk of not having their assessments transmitted and accepted in a timely manner and causing a delay in payments for the facility. The findings included: Record review of Resident #36's face sheet dated 03/06/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #36 had diagnoses including Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), heart disease, anxiety (an unpleasant state of inner turmoil), and diabetes mellitus (a disease in…

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

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as possible to prevent accidents for 1 of 2 hallways (Hall 100) and 1 of 1 oxygen storage areas reviewed for accidents. 1. The facility did not ensure the flooring on Hall 100 was even and free of cracked/broken floor tiles. 2. The facility failed to ensure 1 oxygen cylinder was secured in the oxygen storage area. These failures could place residents at risk for injury. Findings included: 1.During an observation on 03/04/24 at 1:00 p.m., the hallway on Hall 100 had cracked and uneven flooring approximately 3 feet across the floor (side to side). An observation included an ambulatory resident walking over the uneven area. During an observation and interview on 03/05/24 at 9:24 a.m., CNA F said the floor between hall 100 nurses' station and the dining room had been cracked/broken for an unknown amount of time. She said 1 broken spot just occurred about 2-3 weeks ago. She said it could be a trip hazard because she does have residents who walk.…

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 a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on [DATE] at 09:50 a.m., the following medications were observed in the controlled medication storage cabinet awaiting to be disposed: *Alprazolam 0.5mg- 60 tablets *Alprazolam 0.5mg- 1 tablet *Tramadol 50mg- 30 tablets The DON said the controlled medications awaiting to be disposed were kept in the…

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

Based on observations, interviews, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy, as evidenced by: 1.) The facility failed to serve hot spiced apples as part of the noon-time (lunch) meal on 3/5/24 for all residents. The residents were served sherbert ice cream instead. 2) The facility failed to follow puree recipe for chicken fettuccine alfredo served on 3/5/24 (lunch meal) for residents on a puree diet. This failure could affect all residents in the facility who required pureed food consistency by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record Review of the facility week 1 menu received on 3/04/24, indicated the lunch meal items included chicken fettuccine alfredo, green beans, dinner roll, hot spiced apples, margarine, salt/pepper packets, choice of beverage, and water. Record Review of the recipe for the chicken fettuccine alfredo for 5 or less residents on puree indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability, attractiveness, and appetizing . The dietary staff failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 3/5/24 (lunch) meal for all residents. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During an interview on 3/4/24 at 4:10 p.m., Resident #44 stated he did not like the food and the food was not seasoned. During an interview 3/4/24 at 4:11 p.m., Resident #2 stated the facility served the same foods and the food had no flavor. Resident #2 stated he had not eaten at the facility in months. Resident #2 stated he had been living at the facility for a year. During an interview on 3/4/24 at 1:49 p.m., Resident #4 stated the food could be better. Resident#4 stated he wanted his food hot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #43) and 1 of 3 shower rooms (hall 100 shower room) reviewed for infection control practices. 1) Facility failed to ensure [NAME] button extension for Resident #43 was bagged and dated. 2) LVN D failed to wash or sanitize hands and change gloves between dirty and clean while providing bolus feeding for Resident #43. 3) The facility failed to store clean linen away from dirty. These failures could place residents and staff at risk for cross contamination and the spread of infection. Findings included: 1. Record review of Resident #43's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses cerebral palsy (a group 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.