Apex Secure Care Brownfield

Based on observation, interviews, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 treatment carts (treatment cart for Hall A, B and C) reviewed for proper medication storage.LVN C failed to ensure the treatment cart, which contained medications, was not left unlocked and unsupervised in the hallway near the nurse's station.This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversions.During an observation on 10/02/25 at 1:59 PM, the treatment cart for Hall A, B and C was observed sitting outside the nurse's station and was unlocked and unsupervised. The cart was located in close proximity to residents and no staff were present to supervise the cart. Upon inspection of the drawers in the cart with LVN C, prescription medications, creams, and supplies were observed. 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.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 21 confidential residents. The facility failed to ensure 12 of 21 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and Record Review during Resident Council on, 02/10/2025 at 2:00pm, 12 of 21 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting 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 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 store and date foods stored in the refrigerator. 2. The facility failed to ensure foods were served at temperature above 135 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 02/09/25 beginning at 09:45 AM during initial observation of the kitchen: Observed the following in the walk-in refrigerator: Styrofoam cup covered with tin foil on top shelf no label and no date. Bag of white shredded cheese opened with no label and no date. Pie uncovered and no date. Styrofoam cup with lid on top shelf with no label and no date. Observed the following in the panty: Personal jacket on top of open backet with individual syrup condiments. Home cookies in open container in paper sack no date. Personal drink on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 of 20 residents (Resident #27, #51, #328, and Resident #16) reviewed for infection control. 1. CNA A failed to utilize hand hygiene when assisting Residents #27, #51, and #328 with their meals on 2/09/2025. 2. LVN B failed to utilize hand hygiene between glove changes when providing wound care to Resident #16 on 2/10/2025. These failures could place residents at risk for infection, and cross-contamination. Findings include: Resident #27 Record review of Resident #27 undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #27 had a medical history of muscle wasting and atrophy (a condition where muscles shrink and lose mass, resulting in weakness and decreased…

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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. 1. The residents' hand sink in room D5 was not operational for 2 of 3 days. 2. The hand sink in the women's restroom was not operational for 2 of 3 days. 3. The hand sink and toilet in room A8 was not operational for 1 of 3 days. 4. The hand sink and toilet in room A6 was not operational for 1 of 3 days. These failures could place residents and the public at risk of a diminished quality of life due to exposure to an environment that is nonfunctional, uncomfortable, unsanitary, and unsafe. The findings included: During an observation on 2/9/2025 at 10:32 AM the hand sink in residents' room D5 was observed with standing water in the basin of the sink. The water continued to rise in the basin of the sink as the water ran, after being turned on. During an observation on 2/9/2025 at 12:05 PM the toilet in resident's room A6 was observed to be full 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, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 1 (Resident #2) of 21 residents. The facility failed to ensure Resident #2 was treated with respect, dignity, and care when they failed to ensure Resident #2's room was cleaned daily, furnished with a covering on her bedroom window, and a furnished with a privacy curtain. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. Findings Included: Record review of Resident #2 's face sheet dated 02/20/2024 revealed she was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Traumatic subarachnoid hemorrhage with loss of consciousness of 31…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews, the facility failed to ensure each resident had a right to reside and recieve services in the facility with reasonable accomodation of the resident's needs and preferences for 1 (Resident #2) of 21 residents reviewed for accomodation of needs. The facility failed to provide a working communication system, that was easily at reach at the bedside, that would allow Resident #2 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings included: Record review of Resident #2 's face sheet dated 02/20/2024 revealed she was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter (bleeding in the space around 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, interviewn and record review, the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 1 (Resident #2) of 21 resident's rooms and restrooms reviewed for environment. The facility failed to ensure Resident #2's room was cleaned daily, homelike, clean, safe, and did not need repairs. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings included: Record review of Resident #2 's face sheet dated 02/20/2024 revealed she was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 1 of 6 residents (Resident #16) reviewed for PASRR screening, in that: Resident #16 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. These failures could place residents, with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation, at risk for not receiving care and services to meet their needs. The findings included: Resident #16: Record review of Resident #16's electronic face sheet dated revealed a [AGE] year-old male admitted to the facility on [DATE]. The face sheet included the following diagnoses: Type 2 Diabetes (problem in the body where blood sugar levels are not regulated, leading to high blood sugar levels) with Diabetic Neuropathic Arthropathy (nerve damage caused by high blood sugar levels), Unspecified Head Injury, Generalized…

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 an ongoing program to support residents in their choice of activities, facility-sponsored group, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 3 of 21 residents reviewed for activities. The facility: 1. Failed to engage in activities at scheduled times. 2. Failed to offer engaging activity replacement for scheduled activities that were cancelled or not completed. This failure could affect Residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings include: Resident #20 Record review of Resident #20's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, Diabetes (blood sugar issues), heart failure (heart does not pump blood as well as it…

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

Based on observations, interviews, and record reviews, the facility failed to ensure menus were followed for all residents for 2 of 3 (02/10/25 noon meal and 02/11/25 noon meal) meals observed. The facility failed to follow the week 4 menu for two lunch services served at the facility on Monday 02/10/25 and Tuesday 02/11/25. These failures could place residents that eat food from the kitchen at risk of poor intake, and/or weight loss. The findings included: Observation on 02/10/25 at 12:00 PM of dining room lunch meal trays being served consisting of cilantro lime chicken, mashed potatoes, beans, fruit cocktail and beverage. Observation on 02/10/25 at 01:15 PM of test meal tray served consisting of cilantro lime chicken, mashed potatoes, beans, fruit cocktail and beverage. Observation on 02/11/25 at 12:15 PM of dining room lunch meal trays being served consisting of beef goulash, squash medley, mixed green salad, baked cookie, and beverage. Record review Monday Week 4 menu dated 09/27/24 revealed noon menu cilantro lime chicken, rice pilaf, charro beans, tortilla chips, salsa,…

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 maintain and ensure safe and sanitary storage of residents' food items for 3 of 3 refrigerators reviewed for food safety (Room D6, D8, and E9) in that: The refrigerator located in Room D6 did not have a temperature log present for the refrigerator. The refrigerator located in Room D8 did not have a temperature log present for the refrigerator. The refrigerator located in Room E9 did not have a temperature log present for the refrigerator. These failures could place residents at risk for food borne illnesses. Findings include: During an observation on 02/09/2025 at 10:37 AM, Resident Room E9 contained a personal refrigerator. There was not a log present indicating the refrigerator's daily temperatures. The refrigerator contained perishable food items such as mayonnaise and cheese. During an observation on 02/09/2025 at 10:45 AM, Resident Room D6 contained a personal refrigerator. There was not a log present indicating the refrigerator'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 interviews, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for one (Resident #1, 2, 3, 4, 5, and 6) of six residents reviewed for abuse. The facility failed to ensure the Abuse and Neglect Policy was implemented by the facility's staff member, when monitoring tech (MT A) abused Resident #1 and M T B, who witnessed this abuse failed to intervene and report it. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings included: Record review of Resident #1's (R#1) admission Record dated 06/28/24, indicated R#1 was a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses of pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), cognitive communication deficit (difficulty paying attention to a conversation, responding accurately), unspecified symbolic dysfunctions…

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 care plan to meet the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to develop and implement a care plan area for physician order for wound treatment of left above the knee amputation (stump). These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #1: Record Review of Resident #1 face sheet, date retrieved on 05/21/2024, revealed a [AGE] year-old female, admitted on [DATE] with a primary diagnosis of high blood pressure, depression, type 2 diabetes, high blood pressure, heart attack, amputation above the know on both right and left leg. Records Review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS of 14 which means Resident #1 is cognitively intact. Record Review of Resident #1's 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 reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for (Residents #1) resident reviewed for pressure ulcer care, in that: 1. Resident #1's wounds were left uncovered and exposed on the left side above the knee amputation. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: Resident #1: Record Review of Resident #1 face sheet, date retrieved on 05/21/2024, revealed a [AGE] year-old female, admitted on [DATE] with a primary diagnosis of high blood pressure, depression, type 2 diabetes, high blood pressure, heart attack, amputation above the know on both right and left leg.…

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 to help prevent the development and transmission of communicable diseases and infections for 1 of 5 Residents observed for infection control for practices (Resident #1) in that: 1. Facility staff failed to change Resident #1's humidification bottle of oxygen t. The bottle on the oxygen tank was dated 02/04/2024. Resident #1 was observed actively using her oxygen. 2. CNA A failed to wash hands prior and during incontinent care with Resident #1. CNA A failed to use appropriate PPE during incontinent care for Resident #1 that was on barrier precautions for wounds. 3. LVN failed to wash hands before or during wound care for Resident #1. LVN failed to use the appropriate PPE during wound care for Resident #1 that was on barrier precautions for wounds. These failures could place residents at risk for infection…

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. 1)The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions. 2) The facility failed to ensure food and non-food contact surfaces were clean. 3) The facility failed to ensure staff stored personal items in a manner that prevented contamination. 4) The facility failed to ensure food were accurately dated and labeled. 5) The facility failed to protect foods from potential contamination, and 6) The facility failed to ensure staff used good hygienic practices. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following interviews and observations were made during a kitchen tour on 1/7/24 that began at 10:15 AM and concluded at 11:12 AM: There was a spray bottle of Peroxide Multi Surface Cleaner and Disinfectant on a shelf with bread and next to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 24 residents (Residents #2, #26) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #2, #26 prior to administering Asenapine Transdermal Patch (an antipsychotic used to treat the symptoms of schizophrenia; a mental illness that causes disturbed or unusual thinking, loss if interest in life, and strong or inappropriate emotions). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their…

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 sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 10 of 24 resident rooms (C1, C5, C8, C9, C10, D1, D3, D4, D7 and D8), reviewed for environment, in that: 1)The facility failed to ensure resident use equipment was safe and in good repair (C1, C9, C10, D1, D7 and D8). 2) The facility failed to ensure resident use equipment and areas were maintained in a clean manner (C5, D7 and D8). 3) The facility failed to ensure resident use hot water was maintained at a comfortable temperature which was at core body temperature or above (98.6 degrees F) (C8, D1, D3, D4, D7 and D8). These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings included: On 1/7/ 24 and 11:21 AM, an observation was made…

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 menus were followed for 3 of 3 food forms (regular, mechanical soft and puree) for 3 residents (Residents #11, 39 and 48) reviewed during mealtimes. The facility failed to ensure Residents #11, 39 and 48 received their meals according to the menu. This failure could place residents at risk for unwanted weight loss and hunger. The findings included: Resident #11 : Record review of the Order Summary Report for female Resident #11 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed of, schizoaffective disorder, bipolar type (mental disorder), need for assistance with personal care, unspecified dementia (cognitive impairment) and unspecified, protein calorie malnutrition (malnutrition), Vitamin B deficiency, unspecified, and adult failure to thrive. Record review of the Order Summary Report dated 1/8/24 for Resident #11 revealed a diet order stating, regular diet,…

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 food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/8/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 2 of 11 residents voiced concerns related to food palatability. One resident stated the food was cold when it was received. Another Resident stated the food was awful and sucks. The Resident further stated the food had no taste to it. - The following interviews and observations were made during a kitchen tour on 1/8/24 that began at 11:30 AM and concluded at 1:03 PM: On 1/8/24 at 11:30 AM, and interview was conducted with the Dietary Manager. She was informed that a test tray was requested. Regarding the…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in the kitchen and 1 of 4 corridors (Hall C) in that: 1)Live roaches were observed crawling on the walls and floor in the kitchen and floor of 1 of 4 corridors (Hall C), and 2) The pest control program was further compromised due to the facility having harborage areas that were not repaired (holes in walls and loose wallboard). These failures could place residents at risk for foodborne illness and infections. The findings include: ~ The following interviews and observations were made during a kitchen tour that began on 1/7/24 at 10:15 AM and concluded at 11:12 AM: On 1/7/24 at 10:59 AM an adult roach was observed crawling on the floor near the three-compartment sink. During an interview with Dietary staff B on 1/7/24 at 10:59 AM, she stated, there were a few roaches in the kitchen. She added the last time she had seen roaches in the facility was this morning (1/7/24). On 1/7/24 at 11:01 AM an interview was conducted with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 25 residents reviewed (Resident #31) in 1 of 24 resident rooms reviewed: The facility failed to provide a safe environment 1 of 1 resident with a diagnosis of Huntington's disease (Resident #31) related to extension cords on 1/07/24 and 1/08/24. This failure could place residents at risk for injuries from contact with the surrounding environment due to resident involuntary movements. The findings included: Record review of the Order Summary Report dated 1/8/24 for male Resident #31 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Huntington's disease (progressive breakdown (degeneration) of nerve cells in the brain causing involuntary body movements), Dysphasia, oropharyngeal phase (swallowing disorder), cognitive communication deficit (dementia disorder), lack 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 offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 3 of 3 residents (Residents #11, 39 and 48): The facility failed to provide Residents #11, 39 and 48 with their physician ordered therapeutic diets that included pureed, thickened and/or fortified foods for the noon and evening meals on 1/7/24 and the noon meal on 1/8/24. This failure could place residents at risk for hunger, weight loss, aspiration and chemical imbalances. The findings included: Record review of the Order Summary Report for female Resident #11 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis listed of, schizoaffective disorder, bipolar type (mental disorder), need for assistance with personal care, unspecified dementia (cognitive impairment) and unspecified, protein calorie…

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 fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents fed by gastrostomy tube (Resident #31). 1)The facility failed to ensure nursing staff provided G-tube (gastrostomy tube) care in a manner to prevent complications and prevent staff miscommunication related to Resident #31's care on 1/07/24 and 1/08/24. These failures could result in the spread of resident infections. The findings included: Record review of the Order Summary Report dated 1/8/24 for male Resident #31 revealed that the resident was admitted to the facility on [DATE] and was years old [AGE] years old. The resident had diagnoses of Huntington's disease (progressive breakdown (degeneration) of nerve cells in the brain causing involuntary body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals for 1 of 2 residents (Residents #165) reviewed for dialysis, in that: Resident #165 did not have physician's orders for dialysis treatments, graft dressing changes related to dialysis or resident care before and after dialysis. This failure could affect residents receiving dialysis treatments and place them at risk of not receiving proper medical care related to dialysis services resulting in a decline in health. The findings were: Review of Resident #165's face sheet dated 01/07/24 revealed an admission date of 01/05/24 with diagnoses which included: acute and chronic respiratory failure (lung problems), type 2 diabetes mellitus (high blood sugar), and end stage renal disease (kidney disease). Review of the facility's document titled, Resident Matrix, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 3 of 3 meals (1/7/24 - Lunch, 1/7/24 - Supper and 1/8/24 - Lunch) observed for 2 of 2 residents with orders for puréed diet (Residents #39 and 48). The facility failed to provide food that was in a form to meet resident needs, 3 of 3 meals observed (1/7/24 - Lunch, 1/7/24 - Supper and 1/8/24 - Lunch) for 2 of 2 residents with orders for puréed diets (Residents #39 and 48). This failure could place residents at risk of decreased food intake and choking. The findings included: Resident #39 Record review of the Order Summary Report dated 1/8/24 for male Resident #39 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of major depressive disorder (mental disorder), muscle weakness, unspecified, dementia (cognitive decline), generalized anxiety disorder (mental…

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