Capstone Healthcare of Daingerfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to ensure the daily staffing needs were followed according to the facility assessment. This failure could place residents at risk of inadequate care or treatment and a decreased quality of life. Findings included: During a confidential group meeting on 04/22/2025 at 10:30 AM, the group reported getting bed baths instead of showers, call lights not being answered timely, and the CNAs telling them they were short staffed so if they did not respond to a call light timely or were taking too long to assist them that was the reason why they were taking so long. The group reported it made them feel like they should not request assistance from the CNAs. During an interview Anonymous Staff Member #1 said the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 4 of 21 residents (Resident #8, Resident #9, Resident #51, and Resident #11) reviewed for privacy and confidentiality. 1.LVN C failed to ensure she closed the EMR of Resident #8, Resident #9, and Resident #51 before entering residents' room to obtain a blood sugar check and administer medications on 04/21/2025. 2. The facility failed to ensure MA G closed Resident #11's EMR before entering her room to administer her pain medication on 04/21/25. These failures could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medication administration record being accessible to others. Findings included: 1.Record review of a face sheet dated 04/23/2025, revealed Resident # 8 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of chronic obstructive pulmonary disease with acute exacerbation…

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 comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 21 (Resident #2, Resident #6, and Resident #9) residents reviewed for care plans. 1. The facility failed to develop a plan of care for Resident #2's smoking and use of a vape (an electronic cigarette). 2. The facility failed to develop a plan of care specific to Resident #6's use of clozapine (antipsychotic medication used to treat mental/mood disorders) The facility failed to develop a plan of care to indicate Resident #6 was considered by the PASRR process to have serious mental illness and an intellectual disability. 3. The facility failed to care plan Resident #9 was in the memory care unit. These failures could place the residents at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 3 resident (Resident #41) reviewed for enteral nutrition. The facility failed to ensure Resident #41's physician's order for her enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) indicated the type of feeding she was supposed to have been receiving. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: Record review of Resident #41's face sheet dated 04/23/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), epilepsy (seizures), hypertension (high blood pressure), and gastrostomy status (surgical opening in stomach to provide…

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 licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 of 3 staff (MA G, MA F, and LVN C) reviewed for competencies. The facility failed to ensure MA G, MA F, and LVN C were competent in medication administration. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize infections. Findings included: 1. Record review of Resident #41's face sheet dated 04/23/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), epilepsy (seizures), hypertension (high blood pressure), and gastrostomy status (surgical opening in stomach to provide nutrition and medications). Record review of 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 interview and record review the facility failed to ensure that residents were free of significant medication errors for 3 of 10 residents reviewed for pharmacy services. (Resident #'s 23, 31 and 41) 1. The facility failed to ensure Resident #41's metoprolol (blood pressure medication) was not administered when her blood pressure was outside of the ordered parameters on 04/13/2025, 04/16/2025, and 04/21/2025. 2. The facility failed to ensure MA G and MA F did not administer Resident #23's metoprolol (blood pressure medication) on 04/07/2025 and 04/20/2025, when her blood pressure was not within the required parameters per the physician's order. 3. The facility failed to ensure MA F did not administer Resident #31's metoprolol (blood pressure medication) on 04/02/2025, 04/08/2025, and 04/20/2025, when his blood pressure was not within the required parameters per the physician's order. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects 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 observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 21 residents (Resident #'s 55 and 10), 1 of 5 medication carts (200 hall medication cart), and 1 of 1 medication storage rooms reviewed for drugs and biologicals. 1. The facility did not ensure Resident #55's Rexall (pain/ fever relief), Purzee (sleep supplement), and Melatonin (sleep aid) were properly safe and secured on 04/23/2025. 2. The facility failed to ensure a lock box in the Medication Room refrigerator with 2 bottles of Lorazepam (controlled medication for anxiety) was permanently affixed. 3. The facility failed to ensure Resident #10's clobetasol cream (used to reduce swelling, redness, itching, and rashes caused by skin conditions) was properly secured and not left on his nightstand on 04/21/25 and 04/22/25. 4. The facility failed to ensure MA G secured the 200 hall Medication Cart when she…

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

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable for 1 of 3 meals observed on 4/22/2025 (lunch) meal. The failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record review of the menu indicated the lunch meal items on 4/22/2025 included chicken enchiladas, Spanish rice, refried beans, and churro bites. During an interview on 04/21/2025 beginning at 09:39 a.m., Resident # 29 stated sometimes the food was good and sometimes the food was bad. Resident #29 stated the food was a hit and miss. During an interview on 04/21/25 at 12:05 p.m., Resident #26 stated the food was not good. Resident #26 stated the food was not good because of the taste and sometimes she received the food cold. During an interview on 04/21/25 at 09:46 a.m., Resident #56 stated his eggs were cold most…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen and 1 of 4 halls (Hall 400) reviewed for dietary services, in that: 1) The dietary staff failed to label and date all food items. 2) The dietary staff failed to discard expired food items. 3)CNA A did not sanitize her hands in between passing meal trays on the 400 hall. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During an observation of Freezer #1 with the Dietary Manager on 4/21/25 at 9:02 a.m., the following was observed: -(1) container of cranberry juice had no prep date and had a use by date of 4/20/25. -(1) 5-pound container of sour cream had an open date of 4/11/25 and expiration date of 4/18/25. - (1) 1/2-quart container of orange juice was not labeled and had no preparation date or expiration date. - (1) container of Kool aide had a no preparation date and had an expiration date of 4/20/25. - (1) container…

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 develop, implement, and maintain an effective training program for existing staff, consistent with their expected roles for 5 of 21 employees (Administrator, DON, ADON, LVN D, and LVN O) reviewed for required trainings. The facility failed to ensure the Administrator, DON, ADON, LVN D, and LVN O received HIV training upon hire on 10/01/2024. The facility failed to ensure the Administrator, DON, ADON, LVN D, and LVN O received Restraint training upon hire on 10/01/2024. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no HIV training completed upon hire for the following staff: *Administrator (hire date 10/01/2024), *DON (hire date 10/01/2024), *ADON (hire date 10/01/2024), *LVN D (hire date 10/01/2024), *LVN O (hire date 10/01/2024), Record review of the employee files revealed there was no resistant training completed upon hire for the following staff: *Administrator (hire date 10/01/2024),…

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 observations, interviews, and record review, the facility failed to ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 21 residents (Resident #3) reviewed for resident rights. The facility failed ensure Resident #3's foley catheter drainage bag had a privacy cover on 04/21/25 and 04/22/25. This deficient practice could place residents at risk for loss of dignity. Findings included: Record review of Resident #3's face sheet dated 04/23/25 indicated an [AGE] year-old female who admitted to the facility on [DATE]. Resident #3 had diagnoses of diabetes (a group of diseases that result in too much sugar in the blood), dementia (a group of thinking and social symptoms that interferes with daily functioning), protein calorie malnutrition (inadequate intake of food), and urine retention. Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated she was usually…

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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 21 residents (Resident #2) reviewed for reasonable accommodations. The facility failed to ensure Resident #2's call light was within reach while in bed on 04/21/2025. This failure could place residents at risk for a delay in assistance and a decreased quality of life. Findings include: Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness and paralysis of left side of the body), type 2 diabetes mellitus with diabetic neuropathy (insulin resistance, with or without insulin deficiency that induces organ dysfunction) progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity,…

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 each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 21 residents (Resident #11) reviewed for self-determination. The facility failed to ensure Resident #11 was provided showers instead of bed baths per her request. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and decrease their quality of life. Findings included: Record review of Resident #11's face sheet dated 04/23/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included diabetes (a group of diseases that result in too much sugar in the blood), cerebral infarction (stroke), irritable bowel syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation), and need for assistance with personal care. 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 observations, interviews, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 21 residents reviewed for advanced directives. (Resident #41) The facility did not ensure Resident #41's code status was updated when the OOHDNR was signed by the physician on [DATE]. These failures placed the residents at risk of not having their end of life wishes honored. Findings included: Record review of Resident #41's face sheet dated [DATE], indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), epilepsy (seizures), hypertension (high blood pressure), and gastrostomy status (surgical opening in stomach to provide nutrition and medications). The face sheet indicated under the advance directive section Code Status: FULL CODE. Record review of Resident #41's comprehensive care plan dated [DATE], indicated Resident #41's guardian had…

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 prompt efforts were made to resolve grievances for 2 of 21 residents (Resident #'s 8 and #26) reviewed for grievances. 1. The facility did not ensure a grievance was filed for Resident #8's missing black pants and green shirt. 2. The facility did not ensure a grievance was filed for Resident #26's missing black pants. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings included: 1. Record review of Resident #8's face sheet dated 04/23/25, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that result in too much sugar in the blood), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Record review of Resident #8'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 observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 2 of 3 residents reviewed for ADLs. (Resident #11 and 26) The facility failed to ensure Resident #11 and #26 received their showers as scheduled. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings included: 1. Record review of Resident #26's face sheet dated 04/23/25, indicated an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #26 had diagnoses which included congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (irregular heartbeat), muscle weakness, and need for assistance with personal care. Record review of Resident #26's quarterly MDS assessment dated [DATE], indicated Resident #26 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 observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion/and or to prevent further decrease in range of motion for 1 of 4 residents reviewed for range of motion. (Resident #10) The facility to ensure Resident #10's splint for his right-hand contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) was being applied as ordered. This failure could place residents who had limited range of motion at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: Record review of Resident #10's face sheet dated 04/23/25, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hypertension (high blood pressure), right upper arm muscle wasting and atrophy (loss of muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 2 residents (Residents #2) reviewed for accident hazards. The facility failed to ensure Resident #2 did not keep a vape (electronic cigarette) on her over bed table. The facility failed to have documentation that Resident #2 was evaluated for use of electronic cigarette use. This failure could place residents at an increased risk for injury. Findings included: Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness and paralysis of left side of the body), type 2 diabetes mellitus with diabetic neuropathy (insulin resistance, with or without insulin deficiency that induces organ dysfunction) progressive death of nerve fibers, which leads to loss of nerves, increased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #3) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #3's foley catheter was secured on 04/22/2025. This failure could place residents at risk for urinary tract infections, catheter dislodgement and a decreased quality of life. Findings included: Record review of Resident #3's face sheet dated 04/23/25 indicated an [AGE] year-old female who admitted to the facility on [DATE]. Resident #3 had diagnoses of diabetes (a group of diseases that result in too much sugar in the blood), dementia (a group of thinking and social symptoms that interferes with daily functioning), protein calorie malnutrition (inadequate intake of food), and urine retention. Record review of Resident #3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 3 residents (Resident #43 and Resident #23) reviewed for respiratory care. 1. The facility failed to ensure Resident #43's oxygen was administered between 2-3 liters per minute via nasal cannula as prescribed by the physician. 2. The facility failed to ensure Resident #23's nasal cannula was stored properly. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: 1. Record review of the face sheet, dated 04/23/25, revealed Resident #43 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), Hyperlipidemia (blood has too many lipids…

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 are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident's (Resident #'s 50) reviewed for trauma-informed care. The facility did not ensure Resident #50 had a trauma screening that identified possible triggers when Resident #50 had a history of trauma. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 04/23/2025, indicated Resident #50 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses of Wernicke's encephalopathy (a serious neurological condition caused by a deficiency of thiamine (vitamin B1), often due to chronic alcohol use or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 21 residents (Resident #8) reviewed for pharmacy services. The facility failed to ensure MA F accurately reconciled Resident #8's narcotic medication log when she administered Resident #8's acetaminophen-codeine (controlled medication used for pain) tablet on 04/22/25. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Record review of Resident #8's face sheet dated 04/23/25, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult…

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 follow their own established smoking policy for the 1 of 2 residents (Resident #2) reviewed for smoking policies. The facility failed to follow the smoking policy and ensure Resident #2 had a safe smoking evaluation completed. This failure could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking. Findings included: Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (blood flow to the brain affected with weakness and paralysis of left side of the body), type 2 diabetes mellitus with diabetic neuropathy (insulin resistance, with or without insulin deficiency that induces organ dysfunction) progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot…

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 all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, to the administrator of the facility and toother officials for 1 of 4 residents (Resident #3) reviewed for abuse. The facility failed to report an allegation of abuse to the administrator and HHSC when Resident #1 kicked Resident #3's feet when he walked by him on 1/12/25 at 5:20 am. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 02/27/2025 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including depression, hypercholesterolemia (high blood cholesterol that limits blood flow), hypertension (high blood pressure), delusional disorders (mental illness that causes people to have false beliefs), and dementia (degenerative brain disease - loss of memory,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews 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 reviewed for kitchen sanitation in that: 1. Dietary Aide L was not wearing appropriate facial covering restraint while preparing and serving lunch. 2. Hamburger meat was thawing improperly in the dish room sink without running water. 3. Ice maker buildup with brown residue on interior panel. 4. Grease buildup on the vent hood switch in the kitchen area. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: 1. During an observation on 2/25/2024 between 9:00 a.m. and 9:20 a.m., Dietary Aide L was not wearing a facial hair restraint for his goatee and had hair protruding from hair restraint while cleaning the kitchen surfaces. During an observation on 2/25/2024 at 11:52 a.m., Dietary Aide L was serving trays wearing a hair restraint,…

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 for 1 of 4 quarters reviewed for payroll data information. (Quarter 4 2023). The facility failed to submit staffing information to CMS for the 4th quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feeling of well-being within their living environment. Findings included: Record review of the facility's Civil Rights form (3761) dated 02/26/24 indicated the following: 5 RNs 8 LVNs 33 Direct Care Staff 8 Dietary 7 Housekeeping and Laundry 5 All Others During an interview on 02/27/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each Minimum Data Set was electronically completed and transmitted to the CMS System within 14 days after completion for 4 of 18 (Resident #59, #62, #63, and #61) residents reviewed for MDS transmittal in that: Resident #59's, discharge MDS assessment dated [DATE] was not submitted as of 02/26/2024. Resident # 62's discharge MDS assessment dated [DATE] was not submitted as of 02/26/2024. Resident # 63's discharge MDS assessment dated [DATE] was not submitted as of 02/26/2024. Resident # 61's discharge MDS assessment dated [DATE] was not submitted as of 02/26/2024. This deficient practice could place residents at risk of not having their assessments transmitted timely. The findings included: 1.Record review of Resident #59's face sheet dated 02/27/2024 indicated Resident #59 was a [AGE] year-old female, admitted to the facility on [DATE] and discharged on 09/11/2023. Resident #59 had diagnoses including acute embolism of right femoral vein…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 18 residents reviewed for activities. (Residents #27) The facility failed to provide Residents #27 with consistent, scheduled activities. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of the face sheet dated 02/26/24 revealed Resident #27 was [AGE] years old and was admitted on [DATE] with diagnoses including stroke, dementia, and aphasia (a disorder that affects how you communicate). Record review of a quarterly MDS dated [DATE] revealed Resident #27 was rarely/never understood and sometimes understood others. The MDS revealed a BIMS had not been conducted due to the resident being rarely/never understood. The…

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

Based on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 3 of 4 reviewed for qualified dietary staff. The facility failed to ensure the Dietary Manager H, Assistant Dietary Supervisor J and Dietary Aid K met the requirements for a food handling This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses. Findings: During an interview on 2/27/2024 at 9:27 AM, Dietary Aid K said she had been employed as the dishwasher and dessert preparer for 3 years. She said that she was currently in the process of obtaining her food handler certification. During an interview on 2/27/2024 at 9:41 AM, Assistant Dietary Supervisor J said his Food Handler Certification was not current and could not say when it expired. During an interview on 2/27/2024 at 9:50 AM, Dietary Manager H said she had been employed at the facility for over 1 year. She said…

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 an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #3 and Resident #56) reviewed for foley catheters and for 2 of 3 residents reviewed for wound care (Resident #8 and Resident #37). 1 .The facility failed to ensure Resident #3 and Resident #56's foley catheter (tube inserted into the bladder to drain urine) tubing and drainage bag/privacy bags were not dragging/touching the floor under their wheelchairs. 2.The facility failed to perform appropriate hand washing while wound care was performed for Resident #8 and Resident #37. These failures could place residents at risk for cross-contamination, increased risk of infection and the spread of infection. Findings included: 1. Record review of Resident #3's face sheet dated 2/25/24 indicated Resident #3 was an [AGE]…

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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 18 residents reviewed for resident rights. (Resident #45) The facility failed to ensure Resident #45 was served lunch on 02/25/24 at the same time as others at his table. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of a face sheet dated 02/26/24 indicated Resident #45 was [AGE] years old and was admitted on [DATE] with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), vitamin deficiency, and pain in left shoulder. Record review of the MDS dated [DATE] indicated Resident #45 was sometimes understood and sometimes understood others. The MDS indicated a BIMS score of 7 which indicated severe 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 interview and record review the facility failed to ensure the notice to residents when changes in coverage are made to items and services covered by Medicare as soon as is reasonably possible provided to 2 of 3 residents (Resident #3 and Resident #42) reviewed for skilled Medicare services in that: Resident #3 and Resident #42 was not given a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when discharged from skilled services prior to covered days being exhausted. This failure could place residents at risk of not being aware of changes to provided services not covered by Medicare and their financial responsibilities. The findings were: 1. Record review of Resident #3's face sheet, dated 09/19/2023, revealed the resident was admitted on [DATE] with diagnoses that included Anxiety (Intense, excessive, and persistent worry and fear about everyday situations. Fast heart rate, rapid breathing, sweating, and feeling tired may occur), Anemia (a problem of not having enough healthy red blood cells…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 2 of 20 residents reviewed for care plans (Resident #37, Resident #66). 1. The facility failed to implement a comprehensive person-centered care plan for Resident #37's wound care orders. 2.The facility failed to develop and implement a comprehensive person-centered care plan for Resident #66's right upper elbow contracture. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1. Review of a face sheet dated 2/27/2024 indicated Resident #37 was an [AGE] year-old female, admitted on [DATE] with the diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities),…

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 good nurtrition, grooming, and personal and hygiene to residents who were unable to carry out activities of daily living for 1 of 18 resident (Resident #16) reviewed for quality of life. The facility failed to removal facial hair from Resident #16 on his request 02/26/2024. This failure could result in a decrease in resident self-esteem, decrease social interaction and cause depression. Findings included: Record review of Resident #16's face sheet dated 02/26/2024 indicated Resident #16 was an 61- year- old male initially admitted to the facility on [DATE] with a diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) [Primary, Admission], Moderate intellectual disabilities, Unspecified osteoarthritis (a progressive, degenerative joint disease), unspecified site, Essential [primary] hypertension, Other recurrent depressive disorders…

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 assist residents in obtaining routine dental services and assist the resident with making appointment for 1 of 61 (Resident #13) residents reviewed for dental services. The facility failed to assist in providing routine dental services for Residents #13. This failure could affect residents by placing them at risk of oral complications with their gums and teeth, causing pain, infections, and weight loss, resulting in a decreased physical and psycho-social well-being. Findings included: Record review of Resident #13's face sheet dated 2/25/2024 indicated she was a [AGE] year-old female who was admitted on [DATE] with diagnoses including Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it ) , Cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) , Rheumatoid arthritis (a chronic inflammatory disorder usually…

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 a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 of 12 resident personal refrigerators reviewed for food safety. (Resident #4). The facility failed to have a policy regarding use and storage of foods brought to residents. Resident #4's personal refrigerator contained decomposing orange and apple slices. This failure could place residents at risk for not understanding safe food storage practices related to food borne illnesses. Findings include: Record review of a face sheet dated 01/23/2024 indicated Resident #4 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Interstitial pulmonary disease (group of diseases that cause scarring (fibrosis) of the lungs), Heart failure (occurs when the heart muscle does not pump blood as well as it should), and Sequelae of cerebral infarction (occurs…

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.