Brownsville Nursing and Rehabilitation Center

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 food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #100) reviewed for pureed diet needs. The facility failed to provide Resident #100 with her regular pureed diet (that was prescribed for individuals who have difficulty chewing or swallowing food) as designated on her meal ticket on 08/10/25. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met. Record review of Resident #100‘s face sheet dated 11/23/21 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Stroke, Muscle wasting, and dysphasia (difficulty swallowing). Record review of Resident #100‘s quarterly MDS assessment dated [DATE] reflected the resident had active diagnoses including non-traumatic brain dysfunction, Alzheimer’s, Aphasia (difficulty speaking), dysphasia…

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 the residents had the right to be free from abuse, neglect, and misappropriation of property for 6 of 8 residents (Residents #6, #9, #7, and R#10) reviewed for abuse. 1.The facility failed to ensure Resident #6 was free from abuse when Resident #7 dug her nails on Resident #6's left forearm that resulted with multiple skin tears with serosanguineous drainage on 01/02/2025. 2.The facility failed to ensure Resident #9 was free from abuse when Resident #6 hit Resident 9 on her upper left arm with a closed hand on 03/25/2025.3.The facility failed to ensure Resident #7 was free from abuse when Resident #2 slapped Resident #7 on the left side of the face with a closed hand on 03/25/2025. 4.The facility failed to ensure Resident #7 was free from abuse when Resident #6 grabbed Resident #7 by the hair and arm on 04/11/2025. 5.The facility failed to ensure Resident #10 was free from abuse when Resident #6 rolled his wheelchair towards her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 3 (Resident #5, Resident #3, and Resident #2) of 4 residents reviewed for neglect. The facility failed to report allegations of resident neglect for Resident #5 to the State Survey Agency within the allotted time frame of 2 hours on 05/24/25 when Resident #5 had a fall at around 7:30 AM and sustained a serious bodily injury (distal fibular diametaphyseal fracture). The facility failed to report two Resident – to – Resident altercations. One on 11/15/24 between Resident #3 and Resident #2. The other occurred on 03/25/25 with Resident #2 and an unknown resident. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 3 (Resident #2, Resident#3, Resident #4) of 5 residents reviewed for accuracy and completeness of clinical records. 1.The facility failed to ensure LVN A and LVN F correctly completed Resident #4's neuro checks between 05/24/25 and 05/27/25. 2. The facility failed to ensure LVN A documented on Resident #4's electronic medical record; he had a nosebleed after the fall he sustained on 05/24/25. 3. The facility failed to ensure Resident #4's left inferior orbital wall fracture was documented on his electronic medical record. 4. The facility failed to ensure two Resident-to-Resident altercations were documented thoroughly. One altercation between residents on 11/15/2024 between Resident #3 and Resident #2, and the other altercation occurred on 03/25/2025 with Resident #2 and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure the residents right to be informed 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 prefers, for 1 of 5 residents (Resident #3, Resident #6 ) reviewed for consent for antipsychotic medications in that: 1. Resident #3 was prescribed and administered Haldol (an antipsychotic) without prior consent based on information of the benefits, risks, and options available. 2. The facility failed to ensure psychoactive medication consents for Resident #6's were signed and dated by his guardian for the use of Zyprexa (antipsychotic medication), Buspirone (anxiolytic medication), lorazepam (benzodiazepine medication), and Risperidone (antipsychotic medication). These failures could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, 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 interviews, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #3) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #3 was evaluated before administering an antipsychotic (Haldol). This failure could place residents at risk of receiving care and services to meet their needs. The findings included: Record review of Resident #3's admission record dated 06/17/2025, revealed an admission date of 08/15/2024, and a re-admission date on 11/25/2024, with a diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and hallucinations), mood disturbance, and anxiety, and traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after a head injury) with loss of consciousness of 30 minutes or less. Record review of Resident #3's admission MDS, dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to develop 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 need that were identified in the comprehensive assessment for 1 of 5 residents (Resident #2) reviewed for comprehensive person-centered care plans.The facility failed to develop interventions in a comprehensive person-centered care plan for Resident #2 to address his behavior of putting small items in his mouth such as crayons.This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.The Findings include: Record review of Resident #2's admission record dated , revealed a [AGE] year-old male with an admission date of 07/06/2021,with a diagnoses which included Alzheimer's Disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to review and revise comprehensive care plans for 4 residents (Residents, #1, #2, #7, and #6) of 10 residents reviewed comprehensive care plan revisions. 1.The facility failed to review and revise Resident #1's comprehensive person-centered care plan from Full Code Status to DNR Status when ordered DNR was dated [DATE]. 2.The facility failed to review and revise Resident #7's comprehensive person-centered care plan when he had a resident-to-resident altercation with Resident #6 when she grabbed his left forearm and pierced skin with her fingernails which caused multiple skin tears on [DATE] at 5:30 p.m., 3. The facility failed to review and revise Resident #2's comprehensive person-centered care plan when he had a resident-to-resident altercation with Resident #7 when he striked her on the face with a closed hand on [DATE] at 3:00 p.m. 4.The facility failed to review and revise Resident #6's comprehensive person-centered care plan when he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 4 residents (Resident #8) reviewed for therapeutic diets.The facility failed to ensure Resident #8 received a house shake on 07/14/2025 with his breakfast tray as ordered by his physician with orders dated 07/11/2025 for a house shake with meals for malnutrition and a revised order effective 07/14/2025 for a house shake with meals for supplement.This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.Findings Included:Record review of Resident #8's admission sheet dated 07/14/2025, reflected a [AGE] year-old male with an admission date of 01/14/2020, with a diagnoses which included vascular dementia (brain damage caused by multiple strokes), cognitive communication deficit (deficits in communication skills resulting from cognitive impairments like attention, memory,…

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 accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #3) of 5 residents reviewed for pharmacy services. The facility failed to verify there was a physician's order for Haldol (an antipsychotic) and to ensure the order had an indication of its use. This failure could place residents at risk for receiving an antipsychotic medication without a physician's order or an indication for use resulting in a resident receiving a medication which could cause a decline in health status. The findings included: Record review of Resident #3's admission record dated 06/17/2025, revealed an admission date of 08/15/2024, and a re-admission date on 11/25/2024, with a diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 (Resident #3) of 5 residents whose medications were reviewed. The facility failed to act on the facility's Pharmacy Consultant recommendations for Resident #3 ' s Haldol order for 1. An approved psychiatric diagnosis and 2. To have an informed consent on file. This failure could place residents receiving antipsychotic medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. The findings were: Record review of Resident #3's admission record dated 06/17/2025, revealed an admission date of 08/15/2024, and a re-admission date on 11/25/2024, with a diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and hallucinations), mood disturbance, and anxiety, and traumatic…

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's drug regimen was free of unnecessary drugs for 1 (Resident #3) of 5 residents reviewed for medications. The facility failed to have an adequate indication for the use of the medication Haldol (an antipsychotic) for Resident #3 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: Record review of Resident #3's admission record dated 06/17/2025, revealed an admission date of 08/15/2024, and a re-admission date on 11/25/2024, with a diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and hallucinations), mood disturbance, and anxiety, and traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after a head injury) with loss of consciousness of 30 minutes…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 4 residents (Resident #1 and Resident #2 and Resident #7) reviewed for medical records accuracy, in that: 1. Resident #1's March 2025 Treatment Administration Record (TAR) documentation was incomplete. Staff did not sign off on the treatment ordered for Resident #1's wound care. 2. Resident #2's March 2025 TAR documentation was incomplete. Staff did not sign off on the treatment ordered for Resident #2's wound care. Resident #2's April Medication Administration Record (MAR) was incomplete. Staff did not document and sign off on Resident #2's blood sugar checks and insulin orders. 3. Resident #7's April and May 2025 MAR documentation was incomplete. Staff did not document and sign off on Resident #7's order for sliding scale insulin. This deficient practice could affect residents whose records are maintained by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 4 of 4 residents (Resident #1, #2, #3, and #4) reviewed for comprehensive care plans. 1. The facility did not include Resident #1's wound and physician ordered wound care on his care plan. 2. The facility did not include Resident #2's diet and the need for crushed medications on their care plan. 3. The facility did not include Resident #3's diet and the need for crushed medications on their care plan. 4. The facility did not include Resident #2's diet and the need for crushed medications on their care plan. This failure could place residents at risk for not receiving appropriate treatment and services. The findings were: 1. Record review of Resident #1's face sheet, dated 09/12/24, revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 4 residents (Residents #3 and #4), reviewed for pharmaceutical services. 1. The facility failed to obtain and input orders for crushed medication for Resident #3. 2. The facility failed to obtain and input orders for crushed medication for Resident #4. This failure could place residents at risk of not receiving their medication safely. 1. Record review of Resident #3's face sheet, dated 09/11/24, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: metabolic encephalopathy (brain dysfunction caused by problems with your metabolism), acute systolic (congestive) heart failure (when the left ventricle of the heart cant pump blood efficiently), pleural effusion (accumulation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure accurate acquiring and administering of all drugs to meet the need of the resident for four residents (Resident #12, Resident #23, Resident #35, Resident #63) of ten residents reviewed for medications. 1. Resident #12 had four unidentified pills and two capsules in a medication cup on his overbed table that Resident #12 had not taken. 2. The Medication Aide left Resident #12's medications on his bedside table and documented that the medications had been administered. 3. Resident #23 had five medications that were not signed off on the MAR on 06/16/2024 and 06/24/2024. 4. Resident #35 had two medications that were not signed off on the MAR on 06/16/2024 and 06/24/2024. 5. Resident #63 had three medication that were not signed off on the MAR on 06/16/2024 and 06/24/2024. This failure could place residents at risk of not receiving their medications as ordered by their physician.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for two (resident #90 and resident #98) of four residents reviewed for call light. The facility failed to ensure Resident #90 and Resident #98's call lights were within reach. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings were: 1.Record review of Resident #90's admission record dated 06/27/24 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Muscle Weakness (Generalized), Hemiplegia (one sided weakness) and Hemiparesis (weakness of 1 side of body) following cerebral infraction (stroke) affecting left non-dominant side, and Need for Assistance with personal care. Record Review of Resident #90's Quarterly Care Plan revised 12/19/23 revealed the Resident was at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident's right to formulate advance directives for 1 (Resident #356) of 20 residents reviewed for advance directives. The facility failed to ensure that Resident #356s code status was entered in the records at the facility. This deficient practice could place the residents at risk of not having their end of life wishes honored, such as receiving unwanted resuscitative measures. Findings included: Record review of Resident #356's electronic face sheet dated [DATE] reflected he was admitted to the facility on [DATE] and original admission date [DATE]. His diagnoses included Nontraumatic Acute Subdural Hemorrhage (buildup of blood on the surface of the brain), Type 2 Diabetes Mellitus without Complications, Hemiplegia (one sided muscle paralysis or weakness), Essential Primary Hypertension (high blood pressure). Record review of Resident #356's Brief Interview of Mental Status Form had a BIMS score of 10, indicating Resident #356 cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 1 (Resident #356) of 4 residents reviewed for baseline care plan completion. The facility failed to complete the advance directive section in the baseline care plan for Resident #356 within the required 48-hour timeframe. This deficient practice could place the residents at risk of not having their end of life wishes honored, such as receiving unwanted resuscitative measures. Findings included: Record review of Resident #356's electronic face sheet dated 06/24/24 reflected he was admitted to the facility on [DATE] and original admission date 02/13/2024. No advance directive information on this form. His diagnoses included Nontraumatic Acute Subdural Hemorrhage (buildup of blood on the surface of the brain), Type 2 Diabetes Mellitus without Complications, Hemiplegia (one sided muscle paralysis 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #63) reviewed for care plans, in that: The facility failed to ensure Resident #63's comprehensive care plan dated 05/29/2024 reflected she was in the secured unit due to a high risk of elopement. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and no having personalized plans developed to address their specific needs. The Findings included: Record review of Resident #63's face sheet dated 06/11/2024 reflected an [AGE] year-old female with an admission date of 07/11/2023. Resident #63's relevant diagnoses included Alzheimer's disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 2 residents (Resident #255) reviewed for indwelling catheters. The facility failed to prevent Resident #255's urinary catheter tubing from touching the floor. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #255's admission record dated 06/25/24 reflected Resident #255 was admitted to the facility on [DATE]. Resident #255 was an [AGE] year-old male with diagnosis which included benign prostatic hyperplasia without lower urinary tract symptoms (an age-associated prostate gland enlargement that can cause urination difficulty), and acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood. Acute kidney failure develops rapidly over a few hours or days…

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 a resident who needs respiratory care was provided with professional standards of practice for 2 of 4 residents (Resident #258 and Resident #260) reviewed for oxygen in that: 1.Resident #258's oxygen was administered at 3.5 Lpm instead of 2 Lpm via nasal cannula as ordered by physician. 2.Resident #260's oxygen was administered at 2.5 Lpm instead of 3.0 Lpm via nasal cannula as ordered by physician. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care. The findings included: 1.Record review of Resident #258's admission Record dated 06/25/24, revealed an [AGE] year-old female, admitted to facility on 06/14/24. Her diagnosis included: Acute respiratory failure (a sudden inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues), chronic pulmonary edema (a long-term condition that occurs 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and #2) of 7 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #1 was coded in the MDS for a fall. 2. The facility failed to ensure Resident #2 was coded in the MDS for a fall. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #1's physician orders dated [DATE] revealed Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 had diagnoses of Dementia, lack of coordination, Parkinson's(A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and unsteadiness on feet. Record review of Resident #1's comprehensive care plan reflected: The resident has had an actual fall r/t Poor Balance, Poor…

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 enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 3 residents reviewed, in that: A plastic bag with food inside that contained tamales was found in Resident #1's night stand. The food was unlabeled, undated and not refrigerated. This deficient practice could lead to illness due to foodborne pathogens. The findings were: Record review of Resident #1's physician orders dated 05/29/24 revealed Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 had diagnoses of Dementia, lack of coordination, Parkinson's (A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and unsteadiness on feet. Record review of Resident #1's annual MDS dated [DATE] revealed: A score of 8 (moderately impaired) for Brief Interview of 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 interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (R #1) reviewed for accuracy of records. The facility did not document R #1's urostomy bag was changed in the TAR on 01/24/24, 01/31/24 and 02/14/24. The facility did not document a for R #1's left ankle pain on 02/10/24. This failure could place residents at risk of not receiving adequate care and services due to inaccurate reflection of care provided. The findings included: Record review of R #1's face sheet reflected an [AGE] year-old male with original admission date of 01/23/24. His diagnosis included: Traumatic subarachnoid hemorrhage (brain bleed), type 2 diabetes, acute and subacute endocarditis (inflammation of the inner lining of the heart chambers and valves), hypertension, acute infarction of small intestine (loss of blood flow to the small intestine), peritoneal abscess (intra-abdominal…

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 review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 8 residents (Resident # 91) reviewed for comprehensive person-centered care plan in that: Resident #91's comprehensive care plan did not reflect the severe weight loss of the resident. This failure could affect residents who require care at the facility and could result in a deterioration of the resident's health status. The findings were: Record review of Resident #91's face sheet dated 3/28/2023 revealed an eighty-four year old male admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Displaced Intertrochanteric fracture of left femur (a specific type of hip fracture of the bones between the bony protrusions on the thighbone); essential primary hypertension (high blood pressure); unspecified atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart); benign prostatic hyperplasia without lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biological's) to meet the needs of each resident, for 1 of 4 medication carts reviewed. 1 medication was found to be expired in the 200 Hall medication cart. This failure could place residents receiving medications at risk for administering medication incorrectly or missing a dose of medications that could result in ineffective treatment and/or exacerbation of the disease process. Findings include: During an observation on 3/29/2023 at 8:45 AM of the 200 Hall medication cart, 1 bottle of Morphine 100mg/5ml (a non-synthetic narcotic with a high potential for abuse derived from opium that is used for the treatment of pain) was found to have expired January 2023. During an interview with ADON A on 3/29/2023 at 8:52 AM ADON A agreed that the bottle of Morphine 100 mg/5ml had an expiration date 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.

Based on observation and interview the facility failed to ensure medications were stored in accordance with currently accepted professional principles on 1 of 1 medication rooms reviewed. The narcotic lock box located in the medication room refrigerator was not affixed to the refrigerator. This failure could place residents receiving medications at risk for administering medication incorrectly of missing a dose of medications that could result in ineffective treatment and/or exacerbation of the disease process. Findings include: During an observation on 3/29/2023 at 8:30 AM of the medication storage room, the narcotic locked box located inside of the refrigerator was not affixed to the refrigerator. During and interview on 3/29/2023 at 8:35 AM with the DON, the DON acknowledged that the narcotic lock box was not affixed to the refrigerator. The DON stated the consequence of the locked box not being secured would be that someone could take the whole box or leave all the medications located in the box unrefrigerated. During an interview with the ADM on 3/30/2023 at 11:55AM the ADM…

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 infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development of and transmission of communicable disease and infection for 2 (Resident #249 and Resident #252) residents reviewed for infection control. The facility failed to ensure MA A disinfected the blood pressure cuff in between blood pressure checks for Resident #252 and Resident #249. This failure could place residents at risk for cross contamination which could result in infections or illness. Findings included: Observation on 3/28/2023 at 3:52 PM revealed MA A removed the blood pressure cuff from the medication cart. She did not sanitize the blood pressure cuff. MA A placed the blood pressure cuff on Resident #252's wrist. After blood pressure reading was completed, MA A did not clean the blood pressure cuff by sanitizing it with the disinfecting wipes on her cart. The blood pressure cuff was placed on top of the medication cart. Observation on 3/28/2023 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.