Harmony Care at Brookshire

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 (Resident #96) of 4 residents reviewed for enteral nutrition. The facility failed to properly label Resident #96's enteral feeding formula to identify what date, time and by which staff administered and hung the feeding. This failure could place residents who had gastrostomy tube at risk receiving expired fluids. Findings included: Record review Resident #96's Facesheet reflected the resident admitted to the facility on [DATE] with diagnosis of weakness, dysphagia (difficulty swallowing), cognitive communication deficit, need for assistance with personal care, traumatic subarachnoid hemorrhage (bleed in the brain due to trauma) with loss of consciousness of unspecified duration, gastrostomy status. Record review Resident #96's Minimum Data Set (MDS) dated [DATE] Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 6 residents (Residents #83) reviewed for significant medication errors. LVN G failed to administer a substantial amount of potassium CL via GT ( medication used for essential mineral and electrolyte that keep the heart beating regularly, muscles contracting and nerves communicating) to Resident # 83 after dissolving potassium CL in water in the medication cup, on 2/11/26 This failure could place residents at risk of abnormal heart rhythms, and potential hospitalizationRecord review of Resident #83's face sheet dated 2/11/26 revealed a [AGE] year-old female resident that was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #83 had diagnoses included: other cerebral infarction ( a type of ischemic stroke where blood flow to part of the brain id blocked usually by a clot due to occlusion or stenosis (narrowing) of small artery, essential…

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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (secured unit). -The secured unit nurse medication cart A contained opened undated medication. These failures placed residents at risk of receiving expired medication and improperly stored medications which could result in delayed healing.During an observation on [DATE] at 9:58 AM of the nurse medication cart A for the locked unit, the following opened medications were not dated when they were opened:Azelastine HCL Nasal spray 0.1% Fluticasone Propionate Nasal spray 50 mcg In an interview with LVN K, on [DATE] at 9:58AM, she said the medication should be dated when opened and it was good for 30 days and it would not be effective after 30 days. LVN K said she was not aware when…

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

Based on interviews and record review, the facility failed to ensure effective administration to maintain the highest practicable well-being of each resident. The facility operated without an administrator from 08/20/25 to 09/13/25, in the 1 of 1 facility reviewed for administration.Record review of personnel records revealed the Former Administrator was terminated on 08/19/2025, there was no record of a licensed interim or permanent replacement appointed from the period of 08/20/2025 - 09/13/2025. During an interview on 09/13/2025 @ 10:30am with the nurse supervisor, she stated that the facility had not had a facility administrator, since 08/2025. She stated that DON, who was not a state-licensed nursing home administrator, was informally made responsible for the Administrator's tasks. During interview on 09/13/2025 @ 1:00pm with DON, stated that the prior facility administrator was terminated 08/19/2025. She stated she was not aware if Human Resources staff had documentation of a designated full-time acting Administrator since the prior Administrator was terminated. She stated…

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

Based on observation, interviews, and record review, the facility failed to ensure that all staff were trained in the procedures for reporting abuse, neglect, exploitation, or misappropriation of resident property for 6 of 6 facility employees reviewed for training. The facility failed to provide training on the identity of the Abuse Coordinator and the procedures for reporting abuse. This deficient practice has the potential to affect all residents by placing them at risk for unrecognized or unreported abuse due to staff being unaware of who to report to and how to initiate the facility's abuse reporting process. Observation 09/13/2025 @ 2:40pm, during the onsite visit, revealed the facility had not update the signage and posting of the facility's Abuse Coordinator. The posting reflected the Former Abuse Coordinator, who was terminated on 08/19/2025, contact information.During interview on 09/13/2025 @ 1:00pm with DON, stated that the Former Abuse Coordinator was terminated 08/19/2025. She stated the in - service was usually provided by the administrator. She stated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 out of 2 residents (Resident #3) reviewed for environment. - The facility failed to ensure Resident #3's room was clean and a homelike environment. There was sheetrock debris and dust on the resident's floor and on her windowsill. - The facility failed to relocate Resident #3 to another room while sheetrock repair work was actively being performed in her room. This deficient practice could place residents at risk of environmental hazards such as airborne dust, construction debris, noise and physical risk which could lead to a decreased quality of life. Findings included: Record review of Resident #3's Electronic Health Record revealed a [AGE] year-old female with diagnoses including Dementia, Protein Calorie Malnutrition and Paralytic Syndrome (loss of 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.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 5 hallways, (Hall 100 and Hall 400) and the conference room. The facility had live gnats in areas of the facility including Halls 100 and 400, and in the conference room. This failure could place residents at risk for resident health, safety and quality of life. Findings included: In an observation on 07/18/25 at 08:15am approximately 10 gnats were flying around the conference room. In an observation on 07/18/25 at 10:11am, approximately 12 gnats were observed near the dining area in Hall 100. In an observation on 07/18/25 at 12:58pm, approximately 5 gnats were observed flying throughout Hall 400. On 07/18/2025 at 1:11pm, the Pest control log for the last 90 days was requested from the Administrator. The pest control log was not provided. In an interview on 07/18/25 at 2:11pm, the ADON stated they recently had a problem with gnats but reported things had gotten better; it used to be worse. She also reported she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 3 of 5 halls (100-hall, 400-hall and 500-hall). - The facility failed to address discoloration on ceiling tiles throughout the facility. - The facility failed to address missing floor and wall tiles. - The facility failed to address exposed sheetrock in the halls and resident rooms. - The facility failed to address chipped wall paint in the halls and resident rooms. - The facility failed to address damaged exit door handles. - The facility failed to address damaged door frame and door handle to storage room. - The facility failed to address damaged handrails. These deficient practices could place residents at risk of living in an unsafe, unclean and unsanitary environment which could lead to a decreased quality of life. The findings include: An observation on 12/02/2024 between 08:45 AM…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen #1) reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/prepared and discarded after 72 Hours (3 days) per facility policy in Kitchen #1 2. Discolored and debris covered kitchen ceiling vents 3. Discolored shelves in refrigerators This failure could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen on 12/02/24 at 8:04 AM revealed the following. 1. A large rectangular pan with gelatin and fruit in the refrigerator/cooler uncovered and undated/labeled. 2. A square pan of pureed carrots that were not dated. 3. [NAME] residue and dust particles over serving table and food preparation areas in the kitchen. 4 The ice machine was observed to have stains and appearance of rust on the inside and outside 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.

Based on interviews and record review, the facility failed to electronically submit to CMS a complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2024 for the first quarter March 1, 2024 to November 30, 2024). The facility failed to submit PBJ staffing information to CMS for the 4th quarter of the fiscal year 2024. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the CMS PBJ report for FY Quarter 1 2024 (March 1- November 30) indicated the facility did not have licensed nursing/staff coverage 24 hours/day . In an interview with the Administrator on 12/06/24 at 1:17 PM he said he knows the PBJ was submitted and he was not sure if the BOM (Business office manager)…

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 that drugs and biologicals used in the facility were accurately acquired, received, dispensed, and administered in accordance with currently accepted professional standards and failed to remove medications for disposition from current medication supply that were discontinued or the residents had been discharged for 3 of 6 medication carts (100 and 200 hall MA medication cart C, 500 hall nurse cart A, and 400 hall nurse cart B) reviewed. 1. The facility failed to ensure 100 and 200 hall MA medication cart C did not contain discharged residents' medications. 2. The facility failed to ensure 500 hall nurse medication cart A did not have expired medications, discharged resident medication, and discontinued medications. 3. The facility failed to ensure 400 hall nurse medication cart B did not have expired medications, discharged resident medication and discontinued medications. These failures placed all residents at risk of harm or decline in health due to lack of potency of medications and expired…

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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 6 medication carts (500 hall nurse cart A and 400 hall nurse cart B), and failed to ensure all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (400 hall nurse medication B) reviewed for medication storage -The 500-hall nurse medication cart A contained opened undated medication and medication not stored in the original packaging delivered from the pharmacy. -The 400 hall nurses medication cart B contained opened and undated medication, medication not stored in the original delivered packet from the pharmacy, and handwritten resident's name on medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 2 (Resident #168, and Resident 29) of 6 residents reviewed for personal privacy. The facility failed to ensure LVN A locked the computer screen, displaying the name of Resident #168's name and medications, while LVN A was in resident's room administering finger stick and insulin. -The facility failed to provide Resident #29 privacy when providing incontinent care. These failures could place residents' protected HIPAA information at risk of being shared place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. The findings included: 1. During an observation on 12/03/24 at 7:45 a.m., LVN A went into Resident 168's room, and performed a finger stick. LVN A left the computer screen open with Resident 168's medication information showing LVN A came out of the resident's room, prepared the insulin pen, returned to the resident'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 accurately assess each resident's status for 1 of 5 Residents (Resident #7) reviewed for assessment accuracy in that: Resident #7 MDS and care plan were in accurate in that was indentified as being on anti-coagulants/antiplatelets when she was not. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Findings include: Record review of Resident #7's admission record dated 12/3/24 revealed a she was a [AGE] year-old female with an initial admission date of 1/11/23 and a re-admission date of 8/22/24 with diagnoses of unspecified fracture of left femur unspecified fracture of left femur (broken left thigh bone, where the exact location of the fracture on the femur is not specified) and Parkinson's Disease without dyskinesia (Dyskinesias are involuntary, erratic, writhing movements of the face, arms, legs or trunk). Record review of Resident #7's Annual MDS assessment dated [DATE] revealed she…

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 and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #22 and Resident #65) reviewed for care plans. The facility failed to ensure Resident #22's comprehensive care plan addressed hospice. The facility failed to ensure Resident #65's comprehensive care plan addressed residing on the memory care unit. This deficient practice could affect residents by contributing to inadequate care. The findings included: Record review of the facility admission Record dated 12/5/24 revealed that Resident #22 was a [AGE] year-old male with an initial admission date of 1/13/2023 and a re-admission date of 6/20/24. Resident #22 had diagnoses…

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 (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 6 residents (Resident #55 and Resident #28) reviewed for ADLs. The facility failed to ensure Resident #55, and Resident #28 was provided personal grooming(shaving) by facility staff. This failure could place residents at risk for discomfort, and dignity issues. Findings included: Resident #55 Record review of Resident #55's face sheet dated 12/03/24 revealed an [AGE] year-old female was admitted to the facility on 10//01/24. Resident #55 had diagnoses included: dementia (decline in thinking, remembering and reasoning), psychosis (lose touch with reality, heart failure(heart cannot pump enough blood to meet the body's needs), and anxiety disorder (experiences excessive feelings of fear, worry). Record review of Resident #55's admission MDS assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder and bowel received appropriate treatment and services for 1 of 10 residents (Residents #29) reviewed for incontinent care, in that: CNA A did not clean Resident #29's groin, buttocks, or open labia to clean during incontinent care. CNA A used cleaning cloth wipe as the resident had bowel movement, and CNA A put the new brief under the resident's buttock without changing gloves, but the resident's buttock had residual of stool. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #29's face sheet, dated 12/05/2024, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses diagnosis of anxiety disorder ( a condition that causes excessive worry and fear that interferes with daily life), history of falling, need for assistance with personal care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 9 residents (Residents #39) reviewed for significant medication errors. - RN C failed to administer medications as ordered to Resident # 39 by attempting to administer crushed potassium CL micro 20meq ER, which had the instruction, do not crush as ordered. This failure could place residents at risk of abnormal heart rhythms, and potential hospitalization. The findings were: Resident #39 Record review of Resident #39's face sheet dated 12/05/24 revealed a [AGE] year-old male resident that was admitted to the facility on [DATE]. Resident #39 had diagnoses included: heart failure (when the heart cannot pump enough oxygen - rich blood to meet the body's needs), hypokalemia (lower than normal potassium level in the bloodstream), dementia (decline in thinking, remembering, and reasoning), and gastrostomy (a small opening into the abdomen and inserted a tube directly…

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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 Staff (CNA A) reviewed for infection control. - The facility failed to ensure CNA A followed proper hand hygiene during incontinent care. These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings included: Record review of Resident #29's face sheet, dated 12/05/2024, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses that included anxiety disorder (a condition that causes excessive worry and fear that interferes with daily life),) gastro-esophageal reflux disease without esophagitis (gastric reflux), history of falling, need for assistance with personal care, constipation, unspecified, major depressive disorder, recurrent…

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 conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, leading to potential entrapment hazards for 1 (Resident #3) of 6 residents reviewed for safety in rooms. The facility failed to conduct regular inspections of resident bed frames and mattresses to identify risks and problems. Resident #3's bed had a significant gap between the mattress and bedframe. These failures could place residents at risk of injury resultant from equipment malfunction, entrapment, or falls. The finding included: Record review on 12/04/24 at 9:00 am of Resident #3's admission face sheet revealed she was a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included bipolar disorder, current episode manic severe with psychotic features ( a serious mental illness that causes extreme mood swings, along with changes in energy, thinking, behavior, and sleep) type 2 diabetes mellitus with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public on three of five halls observed (hall 100, 400 & 500). Floors on Secured unit (hall 100) were dirty and stained. Resident bathrooms on halls 100 were unkept, unclean, had strong urine odor and unsanitary. Window blinds on halls 100, 500 were bent and torn and Hall 400 vertical blinds had missing slats. Windows on hall 100 has an accumulation of spider webs and green stuff on the outside. The toilet bowls on hall 100 had brown and black stains in them. The tiles in rooms on 100 hall was broken, based boards not affixed to the wall, broken sheet racks and peeling paint on the wall. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation of Hall 100 on 07/10/2024 between 11:10-11:40 AM reveal the following: *room [ROOM NUMBER] had broken floor tiles at…

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 reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #3) of four residents reviewed for accommodation of needs. 1. Resident #3 was taken in the personal vehicle of Driver A to a dialysis appointment. Her wheelchair could not be accommodated, and she was asked to use her walker for mobility. 2. Resident #3 expressed being tired after dialysis and was left to wheel herself without assistance back to her room. This failure could decrease the resident's quality of life, increase anxiety, and put other residents at risk for not having their needs and preferences met. Findings included: Record review of Resident #3's face sheet revealed a seventy-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were end stage renal disease, anxiety disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for two (Resident #1 and Resident #2) of ten residents reviewed for ADL care. 1. Resident #1 had not had a shower since 05/11/24. 2. Resident #2 did not receive his scheduled shower on 05/28/24. These failures could place residents at risk for skin break downs, odor, and diminished quality of life. Findings included: Resident #1 Record review of Resident #1's face sheet revealed a sixty-eight-year-old woman who was readmitted to the facility on [DATE]. Her admitting diagnoses were Parkinson's disease (progressive disorder that affects the nervous system), cerebral infarction (stroke), hypertensive heart failure, and chronic obstructive pulmonary disease (COPD- lung disease). Her face sheet also indicated that she had a C bed with an even room number. Record review of Resident #1's care plan revealed that she had the potential for impairment to skin integrity, fragile…

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 received food that accommodates resident preferences for one (Resident #4) of 3 residents reviewed for food preferences. 1. Resident #4 required total assistance during feedings and was served cold food during mealtimes. This failure could place resident who require assistance from staff during mealtimes at risk of not enjoying meals that meet their preferences. Findings Included: Record review of Resident #4's face sheet revealed an eighty-one-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were hemiplegia (total paralysis) and hemiparesis (partial paralysis) following cerebral infarction affecting left non dominant side, dysphagia (difficulty swallowing), encounter for attention to gastronomy (attention to how food is prepared), and cerebral infarction (stroke). Record review of Resident #4's care plan revealed that she had an ADL self-care performance deficit related to dementia,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet resident's medical, nursing, mental, and psychosocial needs for one (Resident #2) of 8 residents reviewed for care plans. The facility failed to follow the physician orders for Resident #2 in relation to tube feeding. This failure could place 8 residents who receive tube feeding services at risk for not having their needs identified and addressed. Findings include: Record review of Resident #2's face sheet revealed an eighty-three-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses was dementia (memory loss), cerebral infraction, cerebral atherosclerosis (arteries in the brain become hard, thick, and narrow, due to buildup of plaque in artery walls), dysphagia (difficulty swallowing), hyperlipidemia (abnormally high level of fats (lipids). Record review of Resident #2'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 observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards as is possible for one (Resident #1) of six residents reviewed for transfers. CNA A failed to lock Resident #1's wheelchair during a transfer. This failure could place residents who require assistance during transfers at risk for falls and injuries. Findings include: Record review of Resident #1's face sheet revealed a sixty-nine-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses Type 2 Diabetes (the body does not produce enough glucose to energize the cells), heart failure, unspecified dementia (memory loss), unsteadiness on feet, and abnormalities of gait and mobility. Record review of Resident#1's care plan revised 01/21/23 focus area revealed an ADL self-care performance deficit. Interventions detailed that Resident #1 was dependent on staff to move from sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and tub/shower…

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 with residents who were unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #1 and Resident #2) reviewed for ADL's. -Resident #1 fingernails were observed with black debris underneath the nails. -Resident #2 was observed with a moderate amount of facial hair growing on her chin. These failures could place residents at risk for low self-esteem and decrease in dignity. Findings: Resident #1 Record review of Resident #1's face sheet revealed an 60year old female admitted to the facility on originally 03/01/2021 and again on 09/29/2023 with the diagnoses that included the following; malignant otitis externa (severe infection that affects the outer ear canal, skull base, and temporal {temple region of the head}) of left ear, end stage renal disease (pertaining to the kidney), type two diabetes mellitus,…

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 infection for 1 of 5 residents (Resident #1) reviewed for infection. -Resident #1s bedpan was laying on the floor in room over in a corner with no name on bedpan nor was the bedpan bagged. This failure placed resident at risk for unwanted infections. Findings: Record review of Resident #1's face sheet revealed an 60year old female admitted to the facility on originally 03/01/2021 and again on 09/29/2023 with the diagnoses that included the following; malignant otitis externa (severe infection that affects the outer ear canal, skull base, and temporal {temple region of the head}) of left ear, end stage renal disease (pertaining to the kidney), type two diabetes mellitus, hypertension (elevated blood pressure), dependence of renal…

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

Based on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 11-01-23 at 8:55 am, with the Dietary Food Service Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster and the lid and door were opened. Interview on 11-01-23 at 9:00 am, the Dietary Food Service Manager stated the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Interview with the Administrator on 11/03/23 at 3:30 PM revealed the facility did not have a copy of their Policy and Procedure for Food Related and Rubbish Disposal.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 8 residents (Resident #164) reviewed for respect and dignity. -The facility failed to provide Resident #164 privacy when providing incontinent care. This failure could place residents at risk of embarrassment and lower self-esteem. Findings include: Record review of Resident #164's face sheet revealed reflected an 70-year- old female who was originally admitted to the NF facility originally on 02/09/2018 and again readmitted on [DATE]. Resident #164 had with diagnoses that consistedwhich included of the following: cerebral infarction (disrupted blood flow to the brain), hemiplegia (one-sided with paralysis)(and hemiparesis (muscle weakness affecting one side of the body), type 2 diabetes mellitus, vascular dementia (brain damage caused multiple strokes), muscle wasting and atrophy (decrease in size of an organ or tissue), and legal blindness. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 2 resident (Resident #40) reviewed for comprehensive care plans. 1.The facility failed to ensure Resident #40's Foley catheter was secured as ordered by the physician. 2. The facility failed to ensure Resident #40 heels were off loaded as ordered by the physician . These failures could place residents at risk of not receiving needed care and treatments. Findings included: Record review of Resident # 40's face sheet, dated 11/02/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE].Resident #40 had diagnoses which included: elevated white blood cell count, sleep disorder, alcohol dependence, in remission, personal…

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 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 lesser intensity as required in the resident's comprehensive plan of care for 1 of 8 residents (Resident #164) reviewed for specialized rehabilitative services. -The facility failed to ensure Resident #164 received her hand device (cone) to her right contracted hand to prevent further contracture. This failure could place residents at risk for further contractures , skin breakdown, and a decrease in physical capabilities. Findings include: Record review of Resident #164's face sheet reflected a 70-year- old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #164 had diagnoses included: cerebral infarction (disrupted blood flow to the 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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to extent possible for 1 of 8 residents (Resident #164) reviewed for bowel and bladder incontinence. The facility did not provide timely, thorough, or proper incontinent care for Resident #164 to prevent UTI's. This failure could place residents at risk for skin breakdown, urinary tract infections, sepsis, and hospitalization. Findings include: Record review of Resident #164's face sheet reflected a [AGE] year-old female who was originally admitted to the NF on 02/09/2018 and readmitted on [DATE] with diagnoses which included: cerebral infarction (disrupted blood flow to the brain), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), type 2 diabetes mellitus, vascular dementia, muscle wasting and atrophy (decrease in size of an organ 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 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 disease and infections for 1 of 8 residents (Resident #164) reviewed for infection control. 1. The facility failed to ensure CNA ZZ did not touch Resident #164 personal items with soiled gloves after incontinent care was performed. 2. The facility failed to ensure CNA ZZ and CNA TT washed or sanitized their hands after performing incontinent prior to leaving Resident #164's room. These failures could place residents at risk for cross contamination, spread of infections, and decrease in quality of life. Findings: Record review of Resident #164's face sheet reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #164 had diagnoses which included: cerebral infarction (disrupted…

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.