Forest Park Nursing & Rehabilitation

Based on observation, interview and record review the facility failed to ensure medications were secured and inaccessible to unauthorized staff and residents for one medication cart on the second floor reviewed for medication storage.The facility failed to ensure the 2nd floor medication cart was locked when unattended. This failure could place residents at risk for drug diversion, drug overdose, and accidental administration of medications to the wrong residents. Findings included:During an observation and interview, on 01/13/2026 at 2:30 p.m., the second-floor nurse's station medication cart was unlocked. Observation of the unattended cart revealed the surveyor opened the top drawer and it contained biological and medications for residents. The MDS Coordinator walked up, said shit, closed the drawer, locked the cart, and walked behind the nurse's station. When asked who was responsible for the medication cart, LVN A denied the cart was observed unlocked. When informed the cart was observed unlocked and unattended and the MDS coordinator locked the cart, LVN A provided an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's care plan addressed her combative behavior (aggressive and eager to fight or argue) as documented by RN Q on 01/26/25 and ADON F on 01/27/25. Subsequently, on 02/06/25 at 10:22 pm, LVN D and CNA I said Resident #1 was about to fall and as they tried to stop her from falling, Resident #1 became combative and hit her lip which caused her lip to bleed. And on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source 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, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for injury of unknown origin reporting. The facility failed to ensure on 02/02/25 Resident #1's injury of unknown origin was reported to HHSC when the staff did not know why she had a swollen left wrist that was later diagnosed as fractured (broken). This failure could place fall risk residents of getting more injuries, bruises, and pain which could result in emotional turmoil and cause decreased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure In response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, or mistreatment while the investigation was in progress. And report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one (Resident #1) of five residents reviewed for Abuse and Neglect. The facility failed to ensure on 02/02/25 Resident #1's injury of unknown origin was investigated and report sent to HHSC when the staff did know why she had a swollen left wrist that was later diagnosed as fractured (broken). This failure could place residents at risk of getting more injuries, bruises, and pain which could result in emotional turmoil and cause decreased health and psycho-social…

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 residents were free of significant medication errors for one (Resident #2) of five residents reviewed for medications errors in that: The facility administered Clonidine to Resident #2 on multiple occasions outside of the ordered blood pressure parameters. This failure could place residents receiving blood pressure medications at risk for low blood pressure. Findings include: Review of Resident #2's Face Sheet and Minimum Data Set (MDS) dated [DATE] reflected Resident #2 was a was a [AGE] year-old male admitted on [DATE] with diagnoses in part including End Stage Renal Disease (final, permanent stage of chronic kidney disease where kidneys no longer function on their own), and Essential Hypertension (high blood pressure not caused by another medical condition). Review of Care Plan dated 10/15/24 reflected Resident #2 had hypertension which included an intervention to give antihypertensive medications as ordered. Review of Physician G's physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 5 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Hydrocodone-Acetaminophen, a medication to help with pain. This failure could place residents at risk for not receiving prescribed medications. Findings included: The Minimum Data Set (MDS) dated [DATE] reflected Resident #1 was admitted on [DATE], was a [AGE] year-old male, and his diagnoses in part included Depression, difficulty in walking, phantom limb syndrome with pain (feeling pain in a missing body part after amputation), polyneuropathy (malfunction of many nerves outside of the brain or spinal cord), and chronic pain syndrome. The Care Plan dated 11/07/24 reflected Resident #1 required pain management related to chronic pain syndrome, polyneuropathy, and phantom pain and included the intervention to administer pain medication as per…

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 determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 5 residents (Resident #1) reviewed for accurate reconciliation of controlled medications. The facility failed to have an accurate reconciliation and accounting of all controlled medications for one resident (Resident #1) of five residents reviewed for accurate reconciliation of controlled medications. This failure could place residents receiving controlled medications at risk for a lack of availability of controlled medications or unnecessary interruptions in receiving controlled medication due to possible drug diversion. Findings included: The Minimum Data Set (MDS) dated [DATE] reflected Resident #1 was admitted on [DATE], was a [AGE] year-old male, and his diagnoses in part included Depression, difficulty in walking, phantom limb syndrome with pain (feeling pain in a missing body part after…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: - The facility failed to ensure food items stored in walk-in cooler were labeled and dated. - The facility failed to ensure foods stored in the walk-in cooler were stored in a sanitary manner. - The facility failed to ensure foods stored in the walk-in freezer were labeled and dated. - The facility failed to ensure personal food items were not stored in the preparation cooler. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation of the facility's preparation cooler, walk in cooler and walk in freezer on 12/12/24 from 9:57 a.m. to 10:12 a.m., accompanied by the DM, revealed the following: - The preparation cooler had a half-filled water bottle labeled with DA B's name on the second shelf. - The walk-in cooler had an undated or labeled Ziploc bag containing a package of opened…

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 the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine was clean and free of mildew and lime. 2. The facility failed to discard open items stored in the refrigerator that were not sealed. 3. The facility failed to ensure raw meat was stored separately from raw food. 4. The facility failed to ensure an opened food item in dry storage was dated. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the ice machine on 11/12/2024 at 8:56 am revealed the following: The machine inner guard had black build up along the top of the inner guard. Observation of the walk-in refrigerator on 11/12/2024 at 9:01 am revealed the following: -1 30 lb box of bacon dated 11/4/2024 was exposed to the air and an uncooked egg was observed inside the box with the bacon. Observation of the dry storage 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 observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for three of six residents (Residents #1, Resident #2, and Resident #3) reviewed for quality of life. The facility failed to answer Resident #1 and Resident #2 call lights in a timely manner. The failure could place residents at risk for complications associated with delayed care such as skin breakdown and dignity issues. Findings included: Record review of Resident #1's Face Sheet dated July 18, 2024, reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with active diagnosis that included Monoplegia (paralysis) of lower limb, type 2 diabetes, major depressive disorder, unspecified mood disorder, anxiety disorder, muscle weakness, Contracture of muscle right upper arm (permanent tightening of muscle fibers that limit movement). Interview…

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 residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for ADLs. The facility failed to provide shower/bath ADL care according to resident care plan for June 2024. These failures placed residents at risk of not receiving necessary services to maintain good personal hygiene and decreased self- esteem. Findings included: Record review of Resident #1's Face Sheet dated July 18, 2024, reflected she was an [AGE] year old female who admitted to the facility on [DATE] with active diagnosis that included Monoplegia (paralysis) of lower limb, type 2 diabetes, major depressive disorder, unspecified mood disorder, anxiety disorder, muscle weakness, Contracture of muscle right upper arm (permanent tightening of muscle fibers that limit movement). 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 record review and interviews the facility failed to provide or obtain laboratory services to meet the needs of its residents for one (Resident #1) of eight residents reviewed for laboratory services. ADON AA failed to follow-up with Resident #1's PA/MD after he received abnormal lab results on 06/03/24. ADON AA failed to get Resident #1's lab reviewed by PA D on 06/05/24. ADON AA faxed lab results for three residents on 06/05/24 but PA D faxed back responses for only two of the residents' labs which did not include Resident #1's labs. This failure could place residents at risk of not getting adequate and timely care and treatment which could cause declines in their health and psychosocial well-being. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a male who admitted to this facility 08/03/23 with a BIMS Score of 10 (moderate cognitive impairment). He had 1 sided upper extremity impairment and 2 sided lower extremity impairment and substantial maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Resident #1) of eight residents reviewed for medical records. The facility failed to ensure LVN A and LVN B completely document Resident #1's BP checks and monitoring after Resident #1's BP dropped to 83/44 on 06/08/24 and 06/09/24. The facility failed to ensure Resident #1's standing orders from his nephrologist for a renal diet with fluid restrictions was added to his facility Doctor's orders. These failures could affect all residents and cause errors in care, treatments and diets which could result in a decline in their health and psycho-social well-being. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a male who admitted to this facility 08/03/23 with a BIMS Score of 10 (moderate cognitive impairment). He had 1 sided upper extremity impairment and 2 sided lower extremity impairment and substantial maximal…

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 for one (Resident #1) of five residents reviewed for privacy. The facility failed to ensure RN A locked the computer, which showed Resident #1's medication and personal information, after he walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others. This failure could cause residents to feel uncomfortable and disrespected. The findings included: Record review of Resident #1's face sheet. printed on 05/29/24, revealed a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses of fracture of lower left tibia (fracture in the lower leg), type 2 diabetes (high blood sugars), and hyperlipidemia (in excess of lipids or fats in the blood). Record review of Resident #1's quarterly MDS assessment, dated 05/16/24, reflected Resident #1 had a BIMS score of 15, which indicated she was cognitively intact.…

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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one (Resident #2) of five residents reviewed for ADL care. The facility failed to ensure Resident #1 received bath/showers three times a week as per their shower schedule. This failure could place residents at risk of skin breakdown, infection and loss of self-esteem. The findings include: Record review of Resident #2's face sheet, printed on 05/29/24, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of acute osteomyelitis of the left ankle and foot(bone infection), peripheral vascular disease (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), major depressive disorder, type II diabetes (increase blood sugar levels) and acute infective endocarditis (inflammation of the inner…

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 pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 5 residents reviewed for pressure ulcer treatment. The facility failed to ensure Resident #1 received wound care according to physician orders. This failure could place the resident at risk of worsening wounds. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included paralysis following a motor vehicle crash, chronic non-pressure ulcers, and bone infection to lower back. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating she was cognitively intact. Her Functional Status revealed she required extensive assistance with all of her ADLs. Her Skin…

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 who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received incontinent care on 03/15/24. This failure could place residents at risk of impaired skin integrity, and decreased feelings of self-worth and dignity. Findings Include: Record review of Resident #1's electronic face sheet, dated 03/15/24, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included obesity (excessive fat deposits), osteomyelitis (infection of the bone), Encephalopathy (change in brain function), Cellulitis (bacterial skin infection), Difficulty in Walking, Muscle Weakness, Lack of Coordination, Schizophrenia (chronic brain disorder), Acute Congestive Heart Failure (heart does not pump 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident had the right to participate in the development and implementation of his person-centered plan of care for one (Resident #1) of one resident reviewed for person-centered plans of care. The facility failed to include Resident #1 in his Care Plan Conference. This failure could affect residents and place them at-risk by contributing to inadequate care. The findings included: Record review of Resident #1's face sheet, printed 01/26/2024, revealed Resident #1 was a [AGE] year-old male who was admitted to the facility initially on 08/03/2023 and re admitted on [DATE]. The resident had diagnoses which included osteomyelitis (a serious infection of the bone that can be either acute or chronic), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypertension(high blood pressure) Record review of Resident #1's initial MDS dated [DATE] revealed a BIMS score of 10 which…

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 a right to personal privacy for one of three residents (Resident #2) reviewed for personal privacy in that: Caregiver A failed to ensure the door to Resident #2's room was closed while she assisted in dressing Resident #2. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care. Findings included: Review of Resident #2's face sheet, printed 01/16/2024, reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included respiratory failure with hypercapnia (impairment of neuromuscular transmission, mechanical defect of the ribcage and fatigue of the respiratory muscles), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Review of Resident #2's most recent quarterly MDS assessment, dated 10/02/2024, reflected he had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of three residents (Resident #2) reviewed for accuracy of assessment . The facility failed to ensure Resident #2's care plan was revised to include his tendency to undress himself and leave his room undressed. This failure could place residents at risk of receiving care that did not fully address the resident's needs. The findings include: Review of Resident #2's face sheet, printed 01/16/2024, reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included respiratory failure with hypercapnia (impairment of neuromuscular transmission, mechanical defect of the ribcage and fatigue of the respiratory…

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 comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for one of three residents (Resident #2) reviewed for accuracy of assessment . The facility failed to ensure Resident #2's care plan was revised to include his tendency to undress himself and leave his room undressed. This failure could place residents at risk of receiving care that did not fully address the resident's needs. The findings include: Review of Resident #2's face sheet, printed 01/16/2024, reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included respiratory failure with hypercapnia (impairment of neuromuscular transmission, mechanical defect of the ribcage and fatigue of the respiratory muscles), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs).…

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 proper treatment and care to maintain mobility and good foot health for one (Resident #1) of four residents reviewed for podiatrist services. Resident #1 was not seen by a podiatrist for long, thick, and deformed toenails. This failure placed residents at risk of not receiving foot care consistent with professional standards of practice. Findings included: Record review of physician's active orders dated 01/2024 revealed Resident #1 was a [AGE] year-old male admitted to the facility 01/30/23. Diagnoses included high blood pressure, Type II diabetes mellitus and peripheral vascular disease (A progressive circulation disorder that involves the narrowing, blockage, or spasms in the blood vessels). The orders reflected Podiatry to eval and treat. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident's BIMS score was 11 indicating moderately impaired cognition. The MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed ensure Maintain an effective pest control program so that the facility is free of pests and rodents for 5 of 5 residents (Resident #22, Resident #34, Resident #79, Resident #92, and Resident #203) reviewed for environment. 1. The facility failed to ensure Resident #22, Resident #34, Resident #79, Resident #92 and Resident #203 had rooms free from house flies. 2. The facility failed to ensure Resident #92's previous room remained free of pests, specifically bed bugs. These failures could place residents at risk of not receiving an home free of pest and comfortable environment to live. Findings Included: Review of the most recent pest control visit dated from 11/12/22 to 10/14/2023, titled Company name Pest Services, Corrective Action Report, revealed Flying Insects. Treated areas of concern. Need inset fly lights throughout resident hallways. 09/15/23 Bed Bugs. Treated Room [Resident #92's previous room. 10/14/23 Bed Bugs. Treated Room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 (Resident #253) of 5 residents reviewed for accommodation of needs. The facility failed to ensure Resident #253's call light was placed within her reach. This failure could place dependent residents at risk of injuries and unmet needs. The findings included: Review of Resident #253's face sheet, dated 10/17/23 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (a stroke) and hypertension (high blood pressure). Review of Resident #253's care plan, dated 10/12/23, reflected the following: Focus: The resident is (High, Moderate, Low) risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs .Interventions/Tasks: Be sure the resident's call light is within reach and encourage the resident to use it for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with resident rights, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #5) of 5 residents reviewed for comprehensive care plans. Residents #5's care plan did not address her use of a hand splint and towel rolls in her hand and at her elbow. This failure could affect the residents in the facility and could result in services and treatments not being provided. Findings included: Review of Resident #5's face sheet, dated 10/17/23, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included aphasia…

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 for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #35 and Resident#41) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #35 was shaved, not having facial hair, and had her fingernails cleaned and trimmed. 2- Resident #41 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #35's Quarterly MDS assessment dated [DATE] reflected Resident #35 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included hemiplegia (paralysis that affects only one side of the body) affecting right dominant side, muscle weakness, lack of coordination, and type 2 diabetes mellitus. Resident #35's BIMS was 13, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 (Resident #5) of 5 residents reviewed with limited range of motion. The facility did not ensure Resident #5 was receiving contracture management to treat their contracted hands and elbow. This failure could place residents at risk for decrease in mobility, range of motion and contribute to worsening of contractures. Findings included: Review of Resident #5's face sheet, dated 10/17/23, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included aphasia following cerebral infarction (a comprehension and communication [reading, speaking, or writing] disorder resulting from damage or injury to the specific area in the brain after a stroke), stiffness of right hand, stiffness of left hand, contracture (a permanent tightening of the muscles, tendons, skin, 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 interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses cart hall C) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1- LVN D, responsible for nurses cart in hall C, counted controlled drugs every shift change. 2- Medications in unsecure containers were immediately removed from stock. Thes failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: Record review and random count observation of hall C nurse's cart with LVN C on 10/16/2023 at 11:52 AM revealed missing signatures for Off duty and On duty for 10/06/2023, 10/13/2023, 10/15/2023 of the narcotic count sheet. Also, the blister pack for Resident #28's…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine's filter was free from holes; filter and vent was free from dust; the outside of the machine was free from calcium build up and ice chute guard was clean. 2.The facility failed to ensure food items in the kitchen, refrigerator and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in the dry storage were not properly labeled or past the 'best by', consume by or expiration dates. 4. The facility failed to have Dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 5. The facility failed to ensure cooking utensils hanging with clean items were free from food items or liquids 6. The facility failed to ensure cooking utensils…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #5) of 5 residents reviewed for clinical records. The facility failed to ensure staff documented that Resident #5 did not receive her medications on 10/03/23 due to being at the hospital. This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #5's face sheet, dated 10/17/23, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included pain unspecified, disturbances of salivary secretion (an increase in saliva), and hyperlipidemia (high cholesterol). Review of Resident #5's quarterly MDS Assessment, dated 08/21/23, reflected a BIMS score of 99 indicating the resident was unable to complete the interview. Further…

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 obtain information and documentation from hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 (Resident #80) of 5 residents reviewed for hospice services, in that: Facility did not ensure Resident #80's hospice records were a part of their records in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Review of Resident #80's face sheet, dated 10/18/23, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included…

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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #92) of 8 residents reviewed for infection control. The facility failed to ensure: Housekeeper E donned appropriate PPE prior to entering Resident #92's isolated room, and practice proper hand hygiene between change of gloves. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #92's Comprehensive MDS assessment, dated 09/01/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including sepsis (the body's extreme response to an infection), muscle weakness, and lack of coordination. She had a BIMS score of 13 which indicated her cognition was intact. 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 observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for 1 of 1 nurse wound care/ treatment cart (second-floor nurse station wound care/treatment cart) reviewed for drug storage, as evidenced by: the second floor nurse station nurse wound care/treatment cart was left unlocked and unsupervised. This deficient practice could place residents at risk for harm or theft and place the facility at risk for possible drug diversion. The findings include: Observation and interview on 09/01/23 at 2:02 PM revealed an unlocked wound care/treatment cart was left unsupervised and parked by the second-floor nurse station. There was no facility staff near the cart. There was no nurse in charge of the cart at the time of observation. Nurse A walked to the cart after seeing HHSC Investigator documenting contents of Drawer #1. Nurse A stated she did not know who the cart was assigned to. Observations of the wound care/treatment cart contents on 09/01/23 at 2:02 PM revealed in part: -Drawer #1: * 5 Santyl…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of three staff (Cook C) and one of one kitchen reviewed for kitchen sanitation. Cook C failed to properly wear a beard restraint while in the food preparation area. This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 08/23/23 at 11:30 AM of [NAME] C revealed he had facial hair on his chin. [NAME] C was observed in the kitchen walking around food, plates, and the steamtable. [NAME] C had a hair restraint on but not a beard restraint. In an interview on 08/23/23 at 1:15 PM with [NAME] C, he revealed he was only wearing a hair restraint but not a beard restraint. [NAME] C said he knew where the beard restraints were in the kitchen and had access to them he just forgot to put one on today. [NAME] C said the purpose of wearing a hair restraint was to keep his facial hair from falling into food or plates. In an interview 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 observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 2 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to acquire and dispense medications to Resident #1 following admission including Keppra 750 mg used for seizure, gabapentin 800 mg used for pain, Levothyroxine 50 mg used for hypothyroidism, sertraline 100 mg used for depression, and buprenorphine hcl 2 mg used for opioid overdose. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and uncontrolled pain. Findings included: Record review of Resident #1's EHR dated 08/21/23 revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses which included: cellulitis of left hand (a common bacterial skin infection that causes redness,…

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, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented, for 1 of 5 residents (Resident #2) reviewed for complete and accurate records. The facility failed to document the administration or refusals of Resident #2 medication on the MARS or in the clinical record. This failure could place residents at risk of inaccurate needs or services based on comprehensive assessment. Findings included: A record review of Resident #2's electronic face sheet revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), human immunodeficiency virus (a virus that attacks the body's immune system), and Kidney Disease (the kidneys are damaged and cannot filter blood as well…

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 residents received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident # 2) reviewed for accidents. The facility failed to ensure Resident #2 was provided adequate supervision during a shower. This failure could place residents at risk for falls which could result in injury, pain, and hospitalization. Findings Include: A record review of Resident #2's electronic face sheet revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #2's had diagnoses which included Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), human immunodeficiency virus (a virus that attacks the body's immune system), and Kidney Disease (the kidneys are damaged and cannot filter blood as well as they should). A record review of Resident #2's baseline care plan, dated 07/22/23, reflected she required one person physical…

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.