Mustang Park Therapy and Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of five residents (Resident #2) reviewed for dietary services. The facility failed to provide food served that was palatable and thoroughly cooked to Resident #2. This failure could place residents at risk of weight loss, altered nutritional, status, and diminished quality of life. Findings include: A record review of Resident #2's, undated, face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included anxiety (feeling of worry, dread, or fear), diabetes, major depressive disorder (persistent sadness, hopelessness, and loss of interest in activities), morbid obesity, multiple sclerosis (autoimmune disease that affects the central nervous system). A record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS of 15,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside for one of five residents (Resident #1) reviewed for call lights. The facility failed to answer Resident #1's call for assistance in a timely manner due to a malfunction with her call light. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.Findings include: Record review of Resident #1's facility face sheet, dated 11/10/25, revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included cervical disc disorder (affecting the neck's spinal discs, causing pain and discomfort), fusion of spine (surgery to connect two or more bones in any part of the spine), osteoporosis (bones become weak and are likely to break)…

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 right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (Resident #1) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 10/28/2025.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #1's Face Sheet, dated 10/28/2025, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (progressive cognitive decline, memory loss, and behavioral changes) and muscle wasting and atrophy. Record review of Resident #1's Quarterly MDS Assessment, dated 08/14/2025, reflected moderate cognitive impairment with a BIMS score of 08. Resident #1 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 (Resident #2) residents reviewed for infection control.The facility failed to ensure CNA C performed hand hygiene between touching Resident #2's curtain with her bare hand and putting on gloves to apply a clean brief 10/28/2025.This failure could place residents at risk of cross-contamination and development of infections.The findings included:Record review of Resident #2's Face Sheet, dated 10/28/2025, reflected the resident was an [AGE] year-old female who admitted on [DATE]. Resident #2 had diagnoses which included hypertension (high blood pressure), hyperlipidemia (blood has too many lipids, or fats), and vascular dementia (decline in mental ability caused by reduced blood flow to the brain). Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the nurse call system was assessable for six of ten residents (Resident #1, #2, #3, #4, #5 and #6) reviewed for call systems access. The facility failed to ensure the call light system in Resident #1, #2, #3, #4, #5 and #6's rooms was in a position that was accessible to the residents on 10/08/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #1's Face Sheet, dated 10/08/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and muscle weakness. Record review of Resident #1's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance and had an active diagnosis of muscle weakness. Record review of Resident #1'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 ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 4 residents (Resident #9, #10, #11, and #12) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #9, #10, #11, and #12 received their scheduled showers based on records reviewed for September 2025. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings Included: 1. Record review of Resident #9's face sheet, dated 10/08/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis of muscle weakness. Record review of Resident #9's Comprehensive MDS Assessment, dated 07/29/25, reflected her BIMS score of 15 (intact cognitive response). The Comprehensive MDS Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of seven residents (Resident #1, #6, #7, and #8) reviewed for respiratory care. The facility failed to ensure Resident #1, #7, and #8's nasal cannulas were properly stored in a bag when not in use on 10/08/25. The facility failed to ensure Resident #6's tracheostomy hose was not on the floor but properly stored when not in use on 10/08/25. These failures could place the resident at risk for respiratory infection and not having his respiratory needs met.Findings include: 1. Record review of Resident #1's Face Sheet, dated 10/08/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included heart disease. Record review of Resident #1's Quarterly MDS assessment, dated 9/01/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one of six residents (Resident #5) reviewed for dignity. The facility failed to conceal Resident #5's catheter bag lying in public view. This failure placed residents at risk of not having their right to a dignified existence and self-determination maintained.Findings included: Record review of Resident #5's Face Sheet, dated 10/08/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included urinary tract infection. Record review of Resident #5's Quarterly MDS assessment, dated 7/18/25, reflected a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required full assistance. Active diagnosis included renal failure (kidney failure). Record review of Resident #5's Comprehensive…

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 appropriate or obtain from an outside resource routine dental services, to the extend covered under the State plan, and emergency dental services to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for dental. The facility failed to provide proper dental care and assure the denture concerns were addressed with Resident #1. This failure could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being. Findings include: Record review of Resident #1's face sheet, dated 03/28/25, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Chronic Obstructive Pulmonary Disease (lung disease that leads to breathing issues), Dysphagia (difficulty swallowing food or liquids), and Bipolar Disorder (shifts in mood, energy, and activity levels). 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.

Based on interview and record review, the facility failed to electronically submit to CMS 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 fiscal year 2024 for the second quarter (January 1, 2024, to March 31, 2024) reviewed for Administration. The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for January 1, 2024, to March 31, 2024. This failure could place all 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: Record review of an email sent to the Administrator on 01/07/25 at 10:28 AM, indicated the [NAME] 3 Report records from CMS revealed that the PBJ Data for Quarter 2 2024 (January 1,2024 - March 31, 2024) was not submitted. Record review of an email received from the Administrator on 01/07/25 at 12:14 PM,…

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 food that was palatable and attractive for two meals from the facility's only kitchen (lunch meals on 01/7/25 and 01/8/25) reviewed for food and nutrition services. The facility failed to deliver food with an appetizing taste for the lunch meal on 01/07/25 and 01/8/25. The deficient practice could place residents at risk of poor intake of nutrition, weight loss, and a decreased quality of life. Findings included: Observation on 01/7/25 at 12:00 PM revealed the 3 lunch test trays for a regular diet, a pureed diet, and a dysphagia altered diet was tasted by four state surveyors. The meal consisted of Swedish Meatballs, Sliced Glazed Carrots, Egg Noodles, [NAME] Dinner Roll, and spiced peaches. The state surveyors stated the glazed carrots, dinner roll, and noodles were tasteless. Surveyor observed kitchen staff plating the food using warmer plates and a cover. Observation on 01/8/25 at 12:00 PM revealed the 3 lunch test trays for 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 each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or quality of life, recognizing each resident's individuality for 1 (Resident # 24) of 6 residents observed for resident rights. CNA A and CNA B failed to provide Resident #24 with full privacy while he was receiving incontinent care. This failure could place residents at risk of not being treated with dignity and respect. Findings included: Record review of Resident #24's admission Record dated 1/6/25 reflected he was a [AGE] year old male admitted to the facility 4/22/19. Record review of Resident #24's Quarterly MDS assessment dated [DATE] reflected he had severely impaired cognition, he was dependent on staff for toileting, bathing and dressing and required maximum assistance for transfers. He had an indwelling catheter and was frequently incontinent of bowel. His 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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #24) of 3 residents reviewed for catheter care. The facility failed to ensure Resident #24 had a catheter stabilization device. These failures could place residents at risk of urinary tract infections and injury from trauma. Findings included: Record review of Resident #24's admission Record dated 1/6/25 reflected he was a [AGE] year old male admitted to the facility 4/22/19. Record review of Resident #24's Quarterly MDS assessment dated [DATE] reflected he had severely impaired cognition, he was dependent on staff for toileting, bathing and dressing and required maximum assistance for transfers. He had an indwelling catheter and was frequently incontinent of bowel. His diagnoses included hypertension (high blood pressure); urinary tract infection, stroke, hemiplegia (muscle weakness or partial…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #24) of four residents observed for infection control. CNA A and CNA B failed to follow Enhanced Barrier Precautions while providing incontinent care to Resident #24. These failures place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #24's admission Record dated 1/6/25 reflected he was a [AGE] year-old male admitted to the facility 4/22/19. Record review of Resident #24's Quarterly MDS assessment dated [DATE] reflected he had severely impaired cognition, he was dependent on staff for toileting, bathing and dressing and required maximum assistance for transfers. He had an indwelling catheter and was frequently…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. On 03/25/2024 [NAME] F failed to log food temperatures for the dinner service. On 03/26/2024 2 loaves of bread, one bag of hot dogs, and 6 hamburger buns were not labeled with a received or opened date. These failures could place residents at risk for food-borne illness and negatively impact the health and nutrition of residents. Findings included: 1. Observation on 03/26/2024 at 11:40 AM of the food temperature log titled Trayline Temperature Log revealed no food temperatures were written for the 03/25/2024 dinner service. Interview on 03/26/2024 at 11:43 AM with the Dietary Manager revealed the cook was responsible for logging food temperatures before residents were served. The Dietary Manager stated [NAME] F did not log the food temperatures for dinner service. The Dietary Manager stated [NAME] F was a new employee and was still learning. 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 provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for one (Resident #1) of eight resident rooms reviewed for homelike environment. The facility failed to clean Resident #1's bathroom for three days. The deficient practice placed residents at risk of negative psychosocial impacts, infection, illness, and room not feeling homelike. Findings included: Record review of Resident #1's Optional State Assessment MDS dated [DATE] revealed she was a [AGE] year-old female an initial admission date of 08/15/2023 and readmitted to the facility on [DATE] with diagnoses of severe obesity, cellulitis (bacterial infection) of abdominal wall, type 2 diabetes (difficulty managing blood sugar levels), major depressive disorder (mood disorder causing persistent feelings of sadness and loss of interest in activities) and a BIMS score of 14 (cognitively intact). Record review of Resident #1'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 maintain an infection control program designed to prevent the development and transmission of infection for one (Resident #2) of five residents observed for infection control. The facility failed to ensure: LVN G donned the gown when she entered Resident#2's isolation room to provide resident care. This failure could place the residents at risk for infection. Findings include: Record review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses included pressure ulcer of sacral ( the portion of your spine between the lower back and tailbone) region, and cellulitis ( a bacterial infection involving the inner layers of the skin) of left lower limb. Resident #2 required extensive assistance of at least two people with ADLs. He was totally dependent, 2 persons assist with transfers, toileting hygiene, and dressing. assessment revealed BIMS of 15 indicating…

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

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS 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. The facility failed to submit accurate staffing information to CMS for FY Quarter 2 2023 (January 1- March 31). The facility failed to submit accurate licensed nurse hours for 04/09/23, 05/13/23, 06/10/23, 06/11/23, 06/18/23, and 06/25/23. The facility's failures 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 CMS for FY Quarter 2 2023 (January 1-March 31) indicated the facility had failed to submit data for the quarter…

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

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent residents from abuse, neglect, exploitation, and misappropriation of resident property for 2 out of 7 employees (CNA Y and CNA X) reviewed for annual EMR/NAR checks. The facility failed to ensure EMR/NAR checks were completed annually for CNA Y hired 08/04/15 and CNA X hired 07/21/21. This failure could place residents at risk of abuse, neglect, and/or misappropriation of personal property. Findings included: Review of the facility's undated employee list revealed the following staff names and hire dates: CNA Y was hired 08/04/15 and CNA X was hired 07/21/21. Review of CNA Y's latest EMR/NAR search revealed it was run 02/08/18. Review of CNA X's latest EMR/NAR search revealed it was run on 07/01/21. In an interview on 12/06/23 at 3:00 PM with HR stated she had been at the facility for a few months now and was responsible for completing the EMR/NAR searches. HR said she did not know the EMR/NAR searches were supposed to be completed after an employee was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 7 of 10 residents (Residents #2, #9, #22, #27, #39, #44, and #45) reviewed for quarterly assessments, in that: 1. The facility did not ensure Resident #2's Quarterly MDS Assessment, dated 11/02/23, was completed within 92 days of the previous assessment. 2. The facility did not ensure Resident #9's Quarterly MDS Assessment, dated 11/01/23, was completed within 92 days of the previous assessment. 3. The facility did not ensure Resident #22's Quarterly MDS Assessment, dated 11/05/23, was completed within 92 days of the previous assessment. 4. The facility did not ensure Resident #27's Quarterly MDS Assessment, dated 10/13/23, was completed within 92 days of the previous assessment. 5. The facility did not ensure Resident #39's Quarterly MDS Assessment, dated 10/13/23, was completed within 92 days of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete comprehensive assessment for 3 of 7 residents (Residents #48, #59, and #11) reviewed for comprehensive assessments. 1. The MDS Coordinator failed to ensure Resident #11's care plan accurately reflected, paranoid schizophrenia, and use of psychotropic medication Risperidone on 08/23/23. 2. The MDS Coordinator failed to ensure Resident #48's care plan was up-to-date to include her use of psychotropic medication for her active diagnosis of depression. 3. The MDS Coordinator failed to ensure Resident #59's care plan was up-to-date to include her use of the sedative/hypnotic medication Ambien on 11/30/23 and address her IV antibiotic therapy on 11/24/23. These failures could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #11's face sheet, dated 12/07/23, revealed the resident 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.

Based on interview and record review, the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week in the facility for 4 of 60 days (09/02/23, 09/09/23, 09/16/23, and 10/22/23) reviewed for RN coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 09/02/23, 09/09/23, 09/16/23, and 10/22/23. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Review of RN V's time sheets from 09/01/23 to 12/04/23 reflected she worked the following dates and hours: 09/09/23 for 7.63 hours and then 7.38 hours, 10/22/23 for 7.45 hours and then 5.52 hours. Review of RN T's time sheets from 09/01/23 to 12/04/23 reflected she worked the following dates and hours: 10/16/23 for 4 hours and then 3.5 hours. Review of the CNO's time sheets from 09/01/23 to 12/04/23 reflected no hours on 09/02/23. In an interview on 12/07/23 at 11:09 AM with the CNO revealed she was not aware the facility did not have full RN coverage for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 2 halls (Recovery Halls Medication Cart) medication carts and 1 of 5 residents (Resident #37) reviewed for pharmacy services. 1. MA B failed to ensure she did not pre-pop medications in advance and put them in cups on her before she was ready to administer the morning medications to residents. 2. MA B failed to follow the physician orders while administering eye ointment to Resident #37. This failure could place residents at risk of not receiving the therapeutic dose of medication and consuming unsafe medications. Findings included: Review of Resident #37's Quarterly MDS assessment, dated 09/30/23, reflected the resident was [AGE] year-old female who admitted to the facility on [DATE].The resident had diagnoses including acute follicular…

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 have adequate monitoring in place for side effects associated with the use of psychotropic medications and documented in the clinical record for 3 of 5 residents reviewed (Residents #48, #59, and #11) for unnecessary psychotropic drugs. 1. The facility did not monitor Resident #48 for side-effects related to the use of the anti-depression medication Zoloft. 2. The facility did not monitor Resident #59 for side-effects related to the use of the sedative/hypnotic medication Ambien. 3. The facility did not monitor Resident #11 and #51 for side-effects related to the use of the psychotropics and antidepresants medication Risperidone,Geodon from the time they were prescribed . These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Review of Resident #48'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.

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 for one of one kitchen reviewed for food and nutrition services. 1. The facility failed to provide dietary staff with proper handwashing facilities with hot water when the temperature only reached 75 degrees Fahrenheit. 2. Dietary Aide E and Dietary Aide F failed to wear a hair restraint and Dietary Aide G failed to wear a beard restraint while in the facility's kitchen on 12/05/23. 3. The facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation of the kitchen on 12/05/23 at 9:18 AM revealed the kitchen had two handwashing sinks in which the water failed to rise above a moderately warm temperature to touch after running on hot, full, for greater than 1 minute. Further observation revealed Dietary Aide E, and Dietary Aide…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 5 residents (Residents #30 and #44) reviewed for clinical records. 1. The facility failed to ensure staff accurately documented on Resident #30's MAR and in the progress notes regarding his PT/INR lab results on 12/03/23. 2. The facility failed to ensure staff accurately documented on Resident #44's MAR for side effect and behavioral monitoring for her antidepressant medication. These failures could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records. Findings included: 1. Review of Resident #30's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerotic heart disease of native coronary artery without angina…

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 maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5 of 5 residents (Resident #1, Resident# 37 Resident # 39, Resident #46 and Resident #60) reviewed for infection control. 1. MA B and MA C failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #46, #1, #37, #39 and #60 during medication administartion. 2. MA B failed to perform hand hygiene between residents while administering medications to Residents #1, #37 and #46. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident# 1's entry MDS assessment, dated 12/07/23, revealed the resident was [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included elevated blood pressure,…

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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 5 residents (Resident #48) reviewed for accommodation of needs. The facility failed to ensure Resident #48's call light was placed within her reach on 12/05/23. This failure could place dependent residents at risk of injuries and unmet needs. Findings included: Review of Resident #48's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included unspecified psychosis (a condition of the mind that results in difficulties determining what is real and what is not real), and schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Review of Resident #48's Quarterly MDS Assessment, dated 09/26/23, reflected she had a BIMS…

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 coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort including referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for level II resident review upon significant change in status assessment for 1 of 2 residents (Resident #11) reviewed for PASRR. The facility failed to refer Resident #11 to the appropriate state-designated mental health authority for review when he received a new diagnosiss of paranoid schizophrenia on 08/23/23. These failures could affect residents with psychiatric diagnoses who may not be evaluated by the facility and receive needed PASRR services. Findings included: Record review of Resident #11's face sheet, dated 12/07/23, revealed the resident was [AGE] year-old male initially admitted to the facility on [DATE]. His…

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 parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #59) reviewed for peripheral intravenous care. The facility failed to ensure Resident #59 PICC line dressing was dated on 12/03/23. This failure placed residents at risk of developing an infection. Findings included: Review of Resident #59's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included charcot's joint left ankle and foot (a chronic destructive disease of the bone structure), type 2 diabetes mellitus (high level of sugar in the blood), muscular wasting and atrophy (wasting of muscle tissue) and cutaneous abscess of right upper limb (localized collection of pus in the skin and may occur on any skin surface). Review of Resident #59's quarterly MDS…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of three medication carts reviewed for storage of medications. The facility failed to ensure the nurse medication cart for the Recovery Unit was locked when unattended on 12/07/23. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: Observation on 12/07/23 at 1:04 PM revealed medication cart for the Recovery Station parked next to the nurse's station facing the 100 Hall was unlocked. Observed 5 residents around the nurse's station. Medication cart was unattended and unlocked. Interview on 12/07/23 at 1:10 PM with RN D revealed the medication cart located at the nurse's station was last used by her. RN D stated when medication cart were not being used they should be locked. RN D was informed the medication cart was unlocked; RN D stated the medication cart was not far from her. Observed RN D locked the medication cart. RN D stated the risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 1 resident (Resident #30) reviewed for labs and cultures. The facility failed to provide evidence they obtained routine labs for Resident #30's PT/INR levels on 12/02/23 and 12/03/23, as ordered by the physician. This failure could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition(s). Findings included: Review of Resident #30's face sheet, dated 12/07/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body [arteries] become thick and stiff) and atrial fibrillation (a disease of the heart characterized by irregular and often faster…

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 for the maintenance of comfortable sound levels for 3 (Residents #1, #2, and #3) of 6 residents reviewed for comfortable sound levels. The facility failed to maintain a comfortable sound level for Residents #1, #2, and #3 due to Resident #7's yelling. This failure placed residents at risk of being unable to sleep at night. Findings included: Resident #1 Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #1 had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment also indicated the primary reason for admission was medically complex conditions such as type 2 diabetes mellitus without complications, hypertension, obstructive uropathy (a blockage in the urinary tract), and depression. Review of Resident #1's Physician Order dated 09/22/2023 reflected, Venlafaxine HCL ER tablet extended release 24 hrs 150 mg: Give 1 tablet…

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 make prompt efforts to resolve grievances the residents may have for 5 (Residents #1, #2, #3, #4, and #5) of 8 residents reviewed for Grievances. The facility failed to provide prompt response to the grievance of Resident #1 about a person screaming and yelling day and night. The facility failed to provide prompt response to the grievance of Resident #2 about a person yelling and screaming. The facility failed to provide prompt response to the grievance of Resident #3 about a person cursing at staff. The facility failed to provide prompt response to the grievance of Resident #4 about hearing a man scream with his door open or close. The facility failed to provide prompt response to the grievance of Resident #5 about a man who screams all the time demanding immediate attention. This failure could place the residents at risk of not having their grievances resolved when concerns were brought to the attention of the facility. Findings included: 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 observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of eight residents reviewed for ADLs. The facility failed to provide Resident #2 with a shower/bath for 3 Saturdays. The facility failed to provide Resident #3 with a showers/bath on her scheduled days. The resident missed two showers. This failure could place 62 residents who required assistance of 1 or 2 staff or dependent on staff for bathing at risk of not receiving care and services to meet their needs. Findings included: Observation on 10/31/2023 at 9:19 AM revealed the clean linen closet had no available towels. Interview with LVN J on 10/31/2023 at 9:21 AM, LVN J confirmed there were no towels inside the clean linen closet. LVN J stated the CNAs already used the towels that morning for the showers. Resident #2 Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old female admitted…

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 all mechanical, electrical, and patient care equipment in safe operating condition. The facility failed to repair two of three washing machines, which resulted in facility not having adequate supply of bath towels. The facility failed to repair two of three dryers, which resulted in facility not having adequate supply of bath towels. This failure could place 62 residents who required towels for shower/bed bath not having showers because of two of the washers and two of the dryers were not working. Findings included: Observation on 10/31/2023 at 9:19 AM revealed the clean linen closet had no available towels. Interview with Resident #2 on 10/31/2023 at 10:20 AM, Resident #2 stated her shower schedule was on Tuesdays, Thursdays, and Saturdays. Resident #2 said that she would usually get a shower on Tuesdays and Thursdays but not on the weekends. Resident #2 added that this had been going on for a month. Resident #2 said the CNA would tell her that she could not have a shower because there were no…

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.