The Palms Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from abuse, neglect, misappropriations of resident property, and exploitation for 1 (Resident #5) of 5 residents reviewed for abuse. LVN D was verbally abusive to Resident #5 on two occasions on 08/24/25 and 09/05/25. This failure could place residents at risk for physical, mental, and/or psychosocial harm. The findings included:Record review of Resident #5's face sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included paraplegia (the loss of voluntary movement and sensation in both legs), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), metabolic encephalopathy (a chemical, or metabolic, problem in the body that can cause brain dysfunctions such as confusion, memory loss, and/or personality changes), and muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 (Resident #5) of 6 residents reviewed for abuse and neglect. The DON failed to follow the facility's policy to report an allegation of verbal abuse made by Resident #5 on or about 08/24/25 to the administrator, the ombudsman, or to the Texas Health and Human Services Commission (HHSC). This failure could place the residents in the facility at risk for physical, mental, and/or psychosocial harm and lack of timely reporting of incidents.The findings included:Record review of Resident #5's face sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included paraplegia (the loss of voluntary movement and sensation in both legs), anxiety disorder (mental disorder characterized by excessive and persistent worry,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #5) of 6 residents reviewed for reporting. The DON did not report an allegation of verbal abuse made by Resident #5 on or about 08/24/25 to the Administrator, the ombudsman, or the state licensing/certification responsible for surveying/licensing the facility per facility policy. This failure could place residents at risk for physical, mental, and/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 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 for 1 of 3 residents reviewed for PASRR. (Resident #8). The facility failed to refer Resident #8 for PASRR Level II assessment when the facility had coded mental illness on his PASRR Level I assessment. This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning. The findings included: Record review of Resident #8's Resident Face Sheet dated 09/18/25 reflected a [AGE] year-old male with a re-admission date of 09/04/24. Resident #8 had diagnoses which included Type 2 diabetes mellitus with other specified complication (body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), unspecified, Major Depressive disorder, recurrent (mental condition with repeated episodes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene, for one (Resident #86) of 3 residents reviewed for activities of daily living. The facility failed to provide Resident #86 with fingernail grooming. This failure could result in decrease in resident self-esteem, embarrassment, and infections. The findings included: Record review of Resident #86's Resident Face Sheet dated 09/18/25 reflected a [AGE] year-old male with an admission date of 09/27/24. Resident #87 had diagnoses which included Dementia (decline in brain functions such as, memory, thinking, problem-solving & language) in other diseases classified elsewhere, mild, with mood disturbance, Other lack of Coordination (difficulty with voluntary movements & balance), Need for assistance with personal care, Type 2 diabetes mellitus (chronic condition where body does not produce…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #47) residents reviewed for respiratory care. The facility failed to ensure Resident #47's oxygen tubing was changed and documented every night shift on Sunday as ordered. This failure could place residents at an increased risk of infection leading to a decline in health.The findings included: Record review of Resident #47's face sheet dated 09/17/25 revealed a [AGE] year-old male with an admission date of 04/05/24. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (group of diseases that cause chronic inflammation and narrowing of the airways, making it difficult to breathe), and dependence on supplemental oxygen. Record review of Resident #47'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 4 medication carts (2300/2400 Cart) reviewed for storage. The facility failed to ensure the medication cart for halls 2300/2400 was free from expired insulin pens. The failure could place residents in the facility at risk of receiving expired medications from staff. The findings included: Record review of Resident #93's face sheet dated 09/17/25 revealed a [AGE] year-old male with an admission date of 04/13/21. Pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading to high blood sugar levels), and long-term use of insulin. Record review of Resident #93's Quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained due to the resident rarely being understood. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 residents personal refrigerators reviewed for food safety (Resident #114) in that: Resident #114's personal refrigerator located in her room was observed to have 2 slices of pie that were not dated or labeled. This failure could place residents at risk for food-borne illnesses.The findings included: Record review of Resident #114's Resident Face Sheet dated 09/17/25 reflected a [AGE] year-old female with a re-admission date of 08/08/25. Resident #114 had diagnoses which included Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary Admission), Essential (primary) hypertension, Schizophrenia, unspecified. Record review of Resident #114's BIMS score quarterly MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. An observation on 09/16/25…

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 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 1 of 6 residents (Resident #66) reviewed for accuracy and completeness of clinical records. The facility failed to accurately document the glucagon injection (hormone produced by the pancreas that raises blood sugar levels by signaling the liver to release stored glucose) Resident #66 received at approximately 7:45 AM on 07/08/25 in the MAR. This failure could result in residents' records not accurately reflecting the administration of medications and could result in further errors due to inappropriately administering medications twice. The findings included: Record review of Resident #66's face sheet dated 09/17/25 revealed an [AGE] year-old male with an admission date of 10/09/24. Pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 2 resident's bathroom sink (Resident # 43 and #88) and 2 of 5 resident rooms (Resident #76 and Resident #114) reviewed for the environment in that: The bathroom sinks in resident #43's and Resident #88's room were clogged. Resident #76's wall pad and floor mats were torn. Resident #76's nightstand was broken. Resident #114's bathroom sink cabinet door was missing. Resident #114's trim wall trim inside her bedroom was broken off. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortableA record review of Resident #43's Face Sheet 09/16/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #43's diagnoses included Multiple Sclerosis(is a chronic autoimmune disease that affects the central nervous system, leading to a range of neurological symptoms due to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed for pests. The facility failed to maintain an effective pest control program for gnats flying in the dish room of the kitchen, and there was a foul odor in the dish room. These failures could put residents who consumed food from the kitchen at risk for infection and/or food contamination.The findings included: Observation and initial tour of the kitchen on 09/16/25 at 8:15 AM, revealed multiple gnats flying in the dish room and there was a foul odor in the dish room of the kitchen. An interview with the FSM on 09/16/25 at 8:45 a.m., she said the gnats in the dish room had been an on-going problem. Pest control was called and were there about 3 weeks ago. The FMS stated all the walls and floors were washed and scrubbed with disinfectant. Pest control invoices were requested. An interview on 09/18/25 at 4:38 PM with Maintenance Man 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 had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse when CNA-A yelled at and ridiculed Resident #1 on 10/16/2025 as he was requesting assistance. These failures could place residents at risk of physical, mental and emotional decline, psychosocial harm, as well as result in isolation and withdrawal.Findings included: Record review of Resident #1's face sheet, dated 10/16/2025, revealed an [AGE] year-old male first admitted to the facility on [DATE], and a readmission date of 11/18/2024. Pertinent diagnoses included vascular dementia (a type of dementia caused by brain damage from impaired blood flow), major depressive disorder (a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (nagging feelings of worry or anxiety). Record review of Resident #1's Quarterly MDS Assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, and/or mistreatment were reported immediately, but not later than 2 hours after the allegation was made if the allegation involved abuse or resulted in serious bodily injury, or no later than 24 hours if the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including the State) in accordance with state law for 1 of 5 residents (Resident #2) reviewed for abuse and neglect. The facility failed to ensure all alleged possible violations or allegations involving abuse for Resident #2 were reported to the proper entities immediately or as required by law on 10/08/2025. This failure could place residents at an increased risk for abuse or further potential for abuse due to unreported allegations of abuse and neglect.Record review of Resident #2's face sheet, dated 10/14/2025, revealed a [AGE] year-old…

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 in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation or mistreatment while the investigation was in progress for 1 (Resident #2) of 5 residents reviewed for abuse, neglect, and/or misappropriation. The facility failed to do a thorough investigation to include having the CNA and/or charge nurse perform a thorough assessment of the situation and the environment of the residents identified in the abuse allegation the night of 10/08/2025. The facility also failed to have the charge nurse assess the residents identified in the allegation the night of 10/08/2025. This failure could place residents at risk of not having their allegations investigated thoroughly or timely, as well as the potential for abuse to continue.The findings included: Record review of Resident #2's face sheet, dated 10/14/2025, revealed 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.

Based on interviews and record review, the facility failed to report immediately, but not later than 2 hours after the allegation is made, 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, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures by one staff member (the SW) of five staff members reviewed for reporting of abuse allegations. The facility failed to ensure the SW reported all suspected abuse or mistreatment when a handful of residents informed her RN F and RN G were being mean to them approximately between March and April of 2025. This failure could place residents at risk for physical, mental, and psychosocial harm. The findings include: In an anonymous interview, it was stated, night nurses RN F 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 reviews and interviews, the facility failed to ensure residents were free from accident hazards and received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of three residents reviewed for accidents. 1. The facility failed to ensure Resident #2 did not fall out of his bed on 07/08/25 due to CNA C performing incontinent care alone instead of with a second person. This failure could place residents at risk for physical, mental, and psychosocial harm.The findings included: Record review of Resident #2's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged on 07/18/25. His diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis affecting right dominant side (paralysis and weakness on one side of the body), aphasia (an impairment in the ability to read, write, and speak), lack of coordination, seizures (abnormal brain activity which affects muscle control, behavior, and awareness), and history 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 ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 5 of 5 residents (Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7) reviewed for accuracy of records. The facility failed to ensure Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7 had documented Quarterly Elopement Assessments since January 2025. This failure could place residents at risk for improper care due to inaccurate or incomplete assessments and records. Findings included: Record review of Quarterly Assessments for sampled residents (Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7) revealed no quarterly assessments had been completed since 01/16/2025. In an interview with ADON-A on 06/26/2025 at 10:00 AM she stated the Quarterly Elopement Assessments were typically completed either by the charge nurse or one of the ADONs. She stated the previous MDS nurse would create a calendar for when the Quarterly Elopement Assessments…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents were treated in a respectful manner that maintained or enhanced each resident's dignity for 1 (Resident #3) of 6 residents reviewed for dignity. The facility failed to treat Resident #3 with dignity and respect during a post-fall assessment by RN D in Resident #3's room on 05/16/25. RN D asked Resident #3 in a stern tone What is wrong with you and Do you want to break something while Resident #3 was still on the floor post-fall. This failure could place residents who require assistance from nurses at risk of feeling disrespected. Findings included: Record review of Resident #3's face sheet dated 06/19/25 revealed a [AGE] year-old female with an initial admission date of 04/18/25 and a discharge date of 06/19/25. Pertinent diagnosis included Depression. Record review of Resident #3's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 (cognition intact). Record review of Resident #3's comprehensive care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, and if the alleged violation was verified appropriate, corrective action must have been taken for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and/or misappropriation. The facility failed to do a thorough investigation to include interviewing the victim (Resident #1) in the incident, the victim ' s RP, as well as other residents which may have been involved in the incident. This failure placed residents at risk of not having their allegations investigated thoroughly or timely. The findings included: Record review of Resident #1 ' s face sheet dated 11/29/2024 revealed a [AGE] year-old female with an admission date of 07/16/2024. Diagnoses included End Stage Renal Disease (last stage of kidney failure), Anxiety, Type 2 Diabetes (chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #3) of 6 residents reviewed for quality of care. The facility failed to enforce the post-fall assessment policy leading to Resident #3 being moved after a fall prior to checking her vital signs and neurological status on 05/21/25. The failure could affect residents currently residing in the facility, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition. The findings included: Record review of Resident #3's face sheet dated 06/25/25 revealed a [AGE] year-old female with an initial admission date of 04/18/25 and a discharge date of 06/19/25. Pertinent diagnosis included Depression and Muscle Wasting and Atrophy, Record review of Resident #3's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 (cognition intact). 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 accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure LVN-A's medication cart on hall 300 contained an accurate count and record for Resident #1's Clonazepam 0.125 MG (a medication used to treat seizure disorders and panic disorder). This failure could place residents at risk for drug diversion and/or a delay in medication administration, as well as risk of not having allegations investigated throoughly or timely. Findings included: Record review of Resident #1's face sheet dated 11/29/2024 revealed a [AGE] year-old female with an admission date of 07/16/2024. Diagnoses included End Stage Renal Disease (last stage of kidney failure), Anxiety, Type 2 Diabetes (chronic condition which occurs when the body cannot use insulin effectively), and Depression. 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 interviews and record reviews the facility failed to ensure the safe and orderly discharge for one (Resident #1) of four residents. Based on interviews and record review, the facility failed to ensure the safe and orderly discharge for one (Resident #1) of four residents. The facility (Facility A) failed to plan a coordinated discharge and returned Resident #1 back to the discharging facility (Facility B) on the same day. This failure placed Resident #1 in the hospital due to the original discharging facility not accepting the resident. Findings included: Record review of Resident #1's Face sheet dated 4/10/2025 indicated Resident #1 was a [AGE] year old who was admitted with diagnosis of Autistic Disorder (a neurodevelopmental disorder characterized by repetitive, restricted, and inflexible patterns of behavior, interests, and activities, as well as difficulties in social interaction and social communication), Epilepsy (a brain disorder characterized by recurrent seizures, which are episodes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . This failure could place residents at risk for falls, injuries and a decline in health. Findings include: Record review of Resident #1's face sheet, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 with diagnoses which included muscle wasting and atrophy , abnormalities of gait and mobility, lack of coordination, cerebral infarction (stroke) affecting left non-dominant side, and hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which meant mild cognitive…

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 develop and implement a person-centered comprehensive care plan for one (Resident #1) of four residents reviewed. The facility failed to care plan Resident #1's preferences to leave the building and the actions or long-term goals to meet the needs of the resident. This failure could place residents at risk for unmet medical, nursing, mental, and psychosocial needs and preferences. Findings were: On 9/27/2024 at 1:24 p.m. review of face sheet dated 9/19/2023 revealed Resident 1 admitted on [DATE] for major depressive disorder, schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly), and acute gastritis (inflammation of intestine lining) without bleeding. On 9/27/2024 at 1:24 p.m. review of Resident 1's Quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 (Intact). On 9/27/2024 at 1:24 p.m. review of Resident 1's care plan last reviewed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 3 residents (Resident #39) reviewed for preadmission screenings. The facility failed to perform a PASRR for Resident #39 before or after she was admitted on [DATE] with readmission on [DATE]. This failure could place residents at risk of receiving inadequate care. Findings included: Record review of Resident #39's admission record revealed an [AGE] year-old female with an original admission date on 08/13/18 and a readmission on [DATE]. Diagnoses included Alzheimer's, dementia with psychotic disturbance, mood disorder due to known physiological condition, psychotic disorder with delusions due to known physiological condition, anxiety disorder, major depressive disorder, recurrent. Record review of Resident #39's care plan dated 08/02/24 revealed pg. 10 identified a problem dated 10/31/22 of potential for Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 3 residents (Resident #8, Resident #34, and Resident #48) of 18 residents whose care plans were reviewed, in that: 1) Resident #8's comprehensive care plan was not reviewed or revised to include Resident #8's current code status of Full code, instead of Do Not Resuscitate. 2) Resident #34's comprehensive care plan was not reviewed or revised to discontinue Resident #34's use of insulin. 3) Resident #48's comprehensive care plan was not reviewed or revised to discontinue Resident #48's wounds or wound vac (medical device that helps wounds heal by applying negative pressure to the wound site). Resident #48's care plan was also not revised to include that Resident #48 changes out his own urinary catheter monthly. These failures could place residents at risk for inadequate care and services. The findings included: 1.)…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 2 of 2 nutrition rooms (first floor and second floor nutrition room) reviewed for sanitation. The facility failed to maintain the dish room in a safe, sanitary condition. The facility failed to keep the dish room walls and floor clean. The facility failed to keep the ice machine clean and free of leaks. The facility failed to serve juices and milks in clean drinking glasses. The facility failed to keep the air intake filter above the stainless-steel refrigerator clean. The facility failed to keep hot dogs in the refrigerator tightly sealed. The facility failed to maintain 2 chest type freezers in good working order. The facility failed to discard a spatula with peeling edges and kept using it. The facility failed to discard eroded non-stick pans and kept using them. The facility failed to discard dented pans…

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

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed for pests. The facility failed to maintain an effective pest control program for gnats flying in the dish room of the kitchen, and there was a foul odor in the dish room. The facility failed to ensure there was not a method for rodents to enter the kitchen due to a gaping hole in the baseboard. These failures could put residents who consumed food from the kitchen at risk for infection and/or food contamination. The findings included: Observation and initial tour of the kitchen on 08/25/24 at 11:15 a.m., revealed multiple gnats flying in the dish room and there was a foul odor in the dish room of the kitchen. There was a gaping hole approximately 6x6 inches in the base of a wall, adjacent to the floor under the 3-compartment sink. There were what appeared to be rat droppings along the same baseboard near the hole. An interview with the FSM on 08/25/24 at 11:45 a.m., she said she was unaware of the hole…

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 send a copy of the notice of transfer or discharge, and the reasons for the transfer or discharge in writing to the resident, resident representative, or the Office of the State Long-Term Care Ombudsman for two (Residents #37 and #81) of three residents reviewed for transfer and discharge. The facility failed to send the notice of transfer or discharge in writing to Residents #37 and #81, their RP or the Ombudsman when Resident #37 transferred to emergency room on 8/13/24, and Resident #81 was transferred to the hospital on 6/28/2024. This failure could affect residents by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: 1. Record review of Resident #37's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Type 2 Diabetes (disease in which the body has trouble controlling blood…

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

Based on interviews and record reviews the facility failed to refer for a PASRR level II screening who had newly evident or possible serious mental disorder, intellectual disability, or a related condition for review upon a significant change in condition for 1 of 3 residents (Resident #37) reviewed for PASRR. The facility failed to refer Resident #37 for a PASRR level II review after resident received diagnoses of Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, Mood Disorder. This deficient practice could affect residents who received new mental illness diagnoses by not receiving additional evaluations and needed services. The findings included: Record review of Resident #37's Face Sheet revealed an admission date of 9/1/23 with a readmission date of 2/9/24. Diagnoses included Insomnia, Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, Mood Disorder. Review of Resident #37's PASRR evaluation dated 9/1/23 revealed the mental illness…

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 entered the facility with a urinary catheter received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #34) of 4 residents reviewed for urinary catheters in that: The facility failed to ensure that Resident #34 ' s urinary catheter drainage bag did not touch the floor. This failure could place residents who had a urinary catheter at risk for developing or worsening of a urinary tract infection. Findings Included: Record review of Resident #34 ' s face sheet revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Diagnoses included neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), dependence on…

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

Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were safely stored in 1 of 4 medication carts (300-hall cart) reviewed for storage of medications. -The facility failed to ensure disinfectant wipes on the 300-hall medication cart were kept in a separate compartment away from resident's medications. -The facility failed to ensure staff 's personal drink items were not stored in the 300-hall medication cart with resident's medications. This failure could affect residents receiving medications and put them at risk for cross contamination. The findings included: During an observation on 08/28/24 at 10:46 AM, this surveyor opened the 300-hall medication cart and found disinfectant wipes in the same compartment with a variety of resident ' s liquid medications along with one open water bottle and a closed energy drink. In an interview on 8/28/24 at 2:30 PM, RN A stated the personal drink items were hers and they were not supposed to be in the medication cart due to cross-contamination. RN A stated she did not have an answer on why…

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 for 1 of 1 stainless-steel refrigerator, 2 of 2 chest type freezers (freezer A and freezer B), 1 of 1 refrigerator intake filter, 1 of 1 electrical box, and 1 sink drain reviewed for essential equipment in the kitchen. The facility failed to maintain sink drainage in the dish room of the kitchen, and there was a foul odor in the dish room. The facility failed to maintain an electrical box in the dish room of the kitchen. The facility failed to maintain the seals/gaskets on 2 chest type freezers. The facility failed to keep the air intake filter above the stainless-steel refrigerator clean. The facility failed to keep the ice machine clean and free of leaks. These failures could place residents at risk of foodborne illness from improper refrigeration of refrigerated and frozen foods, and potential injury to kitchen staff. The findings were: Observation and Initial tour of the kitchen on 08/25/24 at 11:15 a.m., revealed…

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

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 8 halls (Halls 200, 2200, and 2400) reviewed for environment. 1) The facility failed to keep a storage room containing mouthwash with alcohol on hall 2400 locked while not in use. 2) The facility failed to keep the shower room on hall 200 and hall 2200 locked while not in use. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. The findings included: During an observation on 08/25/2024 at 12:56 PM, a storage room on the 2400 hall was left unlocked while not in use. Inside the storage room was a basket containing approximately 20 unopened bottles of mouthwash containing alcohol. During an observation on 08/25/2024 at 1:21 PM, the shower room on the 200 hall was left unlocked while not in use. Inside the shower room was a bottle of disinfectant left out in the open. During an observation on 08/25/2024 at 1:36 PM, the shower room on the 2200 hall was left…

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 securely store all drugs and biologicals in locked compartments under proper temperature control, and permit only authorized personnel to have access to keys in that: An unknown nurse left Resident #2's discontinued medication in a clear bin, affixed to the ADON's office door, which left it easily accessible to all mobile residents and visitors. These deficient practices could affect residents with medications and could result in missing or misuse of drugs by unauthorized personnel. The findings included: Record review of Resident#2's Face Sheet dated 07/29/2024 revealed, Resident #2 was admitted on [DATE], and was a [AGE] year-old female with diagnoses of dementia (cognitive impairment), cellulitis (tissue inflammation infection), history of urinary problems, and acute cystitis without hematuria (inflammation of the bladder without blood in urine). Record review of Resident #2's MAR dated July 2024, revealed Resident #2 for a URI (Upper…

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 prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for one (Resident #3) of five residents reviewed for infection control, in that: 1. CNA A did not perform hand hygiene during Resident #3's perineal care. 2. CNA A did not perform under foreskin cleansing care of Resident #3's penile area. These failures could place residents at risk for contamination and infection. The findings included: Record review of Resident #3's Face Sheet dated 07/22/2024, originally admitted on [DATE] and readmitted on [DATE], documented a [AGE] year-old male with the following diagnoses of: dementia (cognitive impairment), Acute upper respiratory Failure (serious condition that causes fluid to build up in lungs), and personal history of urinary tract infections. Record review of Resident #3's Face Sheet dated 07/22/2024,…

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 respect the resident's right to personal privacy during care, for one (R#1) of five residents reviewed for privacy issues, in that: CNA A did not provide privacy when providing R#1 with perineal care. This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs. Findings included: Record review of R#1's Face Sheet dated 12/04/2023, admitted [DATE], reveaked she was a [AGE] year-old female with the diagnoses: Dementia (loss of cognitive functioning-thinking, remembering, and reasoning), mood disorder, diabetes mellitus (endocrine disorder), Hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis), end stage renal disease, and neuromuscular dysfunction of bladder. Record review of R #1's MDS dated [DATE], documented a 7/15 BIMS score documenting a severe cognitive impairment. R#1 was coded to be dependent of staff for activities of daily living. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, 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 (R# 1) of five residents reviewed for infection control and transmission-based precautions policies and practices, in that: CNA A did not perform hand hygiene after touching R#1's immediate environment, nor did she perform any glove changes or hand hygiene when cleaning from the R#1's perineal area to R#1's gluteal folds. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of R#1's Face Sheet dated 12/04/2023, admitted [DATE], documented a [AGE] year-old female with the diagnoses: Dementia (loss of cognitive functioning-thinking, remembering, and reasoning), mood disorder, diabetes mellitus (endocrine disorder), Hemiplegia…

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 help prevent the standard and transmission-based precautions to be followed to prevent the spread of infections or diseases for 1 resident, Resident #1 (R#1) , and 1 of 2 staff members who were observed for infection control practices, in that: Restorative Aide A (RA A) did not wash her hands for at least 20 seconds after transfer care. Restorative Aide A (RA A) did not wash her hands for at least 20 seconds after disposing of waste bag in trash bin. These failures could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings included: Record Review of R #1's Minimum Data Set assessment dated [DATE] revealed R#1 required limited assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. Total assistance with transfers, mechanical lift x2 assist for all…

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 During an observation, interview, and record review, the facility failed to ensure the water temperature was safe, clean, comfortable, and homelike for 1 out of 4 halls reviewed for water temperature. The facility did not provide water in the 200 hall shower that was between 100 and 110 degrees F This failure could place residents that resided on Hall 200 at risk for an unpleasant bathing experience, inadequate hygiene, burns, and a decreased quality of life. Findings included: During an interview on 05/08/23 at 08:59 AM with Resident #62 of room [ROOM NUMBER] A, he said that his showers are Monday, Wednesday, and Friday and that the water turns hot or cold regardless of controlling temp on the 200-hall shower room. Resident #62 stated it happened often but not all of the time. Resident #62 stated he needed assistance while showering due to left side weakness but can pretty much shower himself. Resident #62 stated when the water temperature fluctuates, it was hard for him to move and change the temperature of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychosocial needs, for one Residents (R#88) of fourteen residents reviewed for care plans. The facility did not implement the comprehensive person-centered care plan set forth for Resident #88. This failure could place residents at risk for not being provided necessary care and services. The findings included: Review of Resident #88's Face sheet, dated 05/09/2023, documented a [AGE] year-old male admitted on [DATE] and readmitted [DATE] with the diagnosis of depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), muscle wasting, abnormal weight loss, gout (inflammatory arthritis), and hemiplegia (paralysis of one side of the body). 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 ensure a qualified professional directed the activities program for the facility for one of 19 (Activity Director) employees reviewed for compliance. The current facility Activity Director was not a qualified therapeutic recreation specialist or an activities professional who met state licensure requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interest/preferences of each resident. The findings were: Record review of the current Activity Director's (AD) employee file revealed the AD had been employed at the facility as a CNA on 04/07/22. There was no documentation in the AD's employee file the AD had an Activity Director's Certification. In an interview on 05/10/23 at 8:24 AM, the HR said the Activity Director has not finished her program. She enrolled but had not begun the classes. The HR said the current AD was hired on 04/07/23. In an interview on 05/10/23 at 10:02 AM, the current AD said she has…

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, record review, and interview, the facility failed to ensure each resident was free of accident hazards, on hall 2500, for one of three shower rooms observed for chemical accidental hazards. Facility failed to secure the shower room door and securely store chemicals to keep out of reach from any mobile cognitively impaired resident that resided on the second floor. These failures could place residents at risk for accidental poisonous hazards The finding include: During an observation on 05/08/2023 at 01:51 PM, revealed the 2500 hallway shower door had visible blue tape over door jamb and door knob latch plate. This surveyor easily entered the shower room without needing to enter any combination on the combination pad. There was a full gallon of unlabeled questionable orange liquid chemical, which was situated on the floor. During the observation there were multiple residents traveling through the 2500 hallway. During an interview and observation on 05/08/23 at 02:06 PM, the Maintenance Director, stated the shower in 2500 hall shower was not in use, and stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that one resident with an indwelling urinary catheter received appropriate treatment and services for one (Resident #3) of three residents reviewed for urinary catheters, in that: CNA A did not ensure Resident #3's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in Resident #3's physician's orders. Resident #3's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning. Back-flow of urine was observed during the catheter cleaning as well as when CNA A held indwelling catheter, in midair, above shoulder length, for three to five seconds. These failures could place residents with indwelling urinary catheters at risk of infection. The findings include: Record review of Resident #3's Face Sheet dated 05/10/2023, documented a [AGE] year-old female…

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

Based on interviews, and record review, the facility failed to designate a person to serve as director of food and nutrition services who is a certified dietary manager 1 of 1 facility staff in that: The facility has been without a certified dietary manager since October 2020. This failure could result in the dietary needs of all residents served by the kitchen not being met. Findings included: Interview with Dietary Manager (DM) on 5/7/2023 at 9:30am revealed, DM does not currently have a Certified Dietary Manger certification (CDM) but is enrolled currently in the program with the University of Florida. DM stated she has about five months left to complete the program. DM stated, she has been working as the Dietary Manager as of 10/12/2020, with this facility and was hired for the position of Dietary Manger. DM was enrolled in the Certified Dietary Manger course upon hire but did not complete it in time and did not receive her certification. A Personnel file review on 5/10/2023 revealed that the facility's current Dietary Manager was hired on 10/12/2020. The file contained…

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 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 (CNA A) of three staff that were observed for infection control and transmission-based precautions policies and practices, in that: CNA A did not remove her contaminated gloves after touching multiple surfaces prior to commencement of perineal foley catheter cleansing, as well as maintained usage of same contaminated gloves during perineal catheter foley care and did not perform hand hygiene during care procedure. These failures could place residents at risk for infection through cross contamination of pathogens. The findings include: Record review of Resident #3's Face Sheet dated 05/10/2023, documented a [AGE] year-old female admitted [DATE], with readmission date 05/26/2022, with the diagnoses 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.